OF   THE 


>  .r    ^iit»»«rsitg  of  ^aliloitnia. 


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^ 


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Name  of  Book  and  Volume, 


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Division 
Range 

Shelf. 

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j   University  of  cdiioi  aia. 

THE  rvlEDICAL  LIBRARY 


I 
I 


\'.    J  .     I'(  >  r  WCr  1:  A  I'D.     .\I  .    I  >. 

■    Of  San  Francisco. 

PRESENTED  BY  MES.  AND  MISS  FOURGEAUD. 
ri:intf  tiiv.  is:.;. 


THE 


DISEASES  OF  THE  EAR. 


THE 


DISEASES   OF   THE   EAR: 


NATURE,  DIAGNOSIS,  AND  TREATMENT. 


JOSEPH  TOYNBEE,  F.R.S., 

FELLOW    OF    THE    ROYAL    COLLEGE    OP    SURGEONS    OF    ENGLAND;    AURAL    SURGEON    Tu, 
AND    LECTURER   ON   AURAL    SURGERY   AT,    ST.    MARY'S    HOSPITAL;    AURAL    SUR- 
GEON   TO   THE    ASYLUM    FOR    IDIOTS  ;    CONSULTING   AURAL    SURGEON    TO 
THE    ASYLUM    FOR   THE    DEAF    AND    DUMB;    AND    CONSULTING 
SURGEON    TO    THE    ST.    GEORGE'S    AND    ST.    JAMES'S 
GENERAL    DISPENSARY,    LONDON. 


AVITH   ONE   HUNDEED   ENGRAVINGS    ON  WOOD. 


PHILADELPHIA: 

BLANCHARD    AND    LEA. 

186  0. 


^ 


C.  SHERMAK  A  SON,  PRINTERS, 
Corner  SerentU  and  Cherry  Streets,  Philadelphia. 


y- 


I 


THIS  VOLUME  IS  DEDICATED 

TO    THE 

(Sobcrnors  of  St.  Ularg's  Daspital  $011^011, 

WHO,    BY   ESTABLISHING   AURAL   SURGERY   AS   A   DISTINCT   DEPARTMENT 

OF    STUDY   IN   THEIR   HOSPITAL   AND    MEDICAL    SCHOOL, 

EVINCED    A   DESIRE   TO 

ELEVATE   THE   SUBJECT  OF  DISEASES   OF   THE   EAR   TO   ITS   DUE  POSITION, 

AS   A   BRANCH    OF   PROFESSIONAL    KNOWLEDGE 

BASED   UPON    CLINICAL   OBSERVATION    AND    SCIENTIFIC   RESEARCH. 


PREFACE. 


Ix  preparing  the  i^resent  work,  it  has  been  my  aim  to 
produce  a  practical  treatise  on  the  Diseases  of  the  Ear, 
having  for  its  foundation  the  anatomy,  physiology,  and 
pathology  of  the  organ.  This  volume,  however,  does  not 
profess  to  give  a  complete  description  of  the  structure  and 
functions  of  the  Ear:  it  will  be  perceived  that  the  domains 
of  anatomy  and  physiology  have  only  been  entered  upon 
when  requisite  for  the  elucidation  of  the  pathology  or  treat- 
ment. 

And  now,  after  twenty  years'  labor,  seeing  this  volume 
complete,  I  cannot  but  regret  that  it  is  not  more  worthy  of 
its  subject,  and  of  the  inteUigence  of  the  Medical  Profes- 
sion, to  which  it  is  addressed.  It  only  remains  for  me  to 
continue  to  devote  myself  to  my  labors.  And  thus,  while  I 
sincerely  thank  the  numerous  members  of  the  Profession  for 
their  generous  assistance,  in  supplying  me  with  the  larger 
part  of  the  means  of  research  which  I  have  enjoyed,  I  beg 
stiU  further  to  solicit  their  aid.  Long  engaged  upon  another 
work,  in  the  shape  of  "  lUustrations  of  the  Pathology  of  the 
Ear,"  for  which  I  possess  a  large  amount  of  material,  I 
nevertheless  require  much  more.     Indeed,  even  since  this 


Vlll  PREFACE. 

volume  has  been  passing  through  the  press,  two  recent  spe- 
cimens, received  from  medical  men  in  the  country,  have 
elucidated  two  entire  series  of  preparations  in  my  Museum.^ 

I  need  scarcely  draw  attention  to  the  beautiful  illustra- 
tions in  this  volume,  which,  with  two  or  three  exceptions, 
were  drawn  from  nature,  on  wood,  by  Mr.  Ford. 

Few  references  having  been  made  in  the  body  of  this 
volume,  to  the  investigations  on  wliic^i  it  is  founded,  I  have 
given,  in  an  Appendix,  a  list  of  my  published  papers,  to- 
gether with  their  dates,  so  that  the  reader  may  refer  to  them 
when  he  thinks  it  desirable  to  do  so. 

*  It  always  affords  nie  much  pleasure  to  show  my  Museum  to  medical  men. 
18  Savile  Row,  January  20,  1S60. 


CONTENTS. 


CHAPTER  I. 

INTRODUCTION. 

PAGB 

Neglect  of  the  study  of  the  morbid  anatomy  of  the  ear,  the  cause  of  our  igno- 
rance of  aural  surgery — Mode  of  investigating  the  diseases  of  the  ear 
— Method  of  dissecting  the  ear,      ........       33 


CHAPTER  11. 

THE  EXTERNAL  EAR. 

Anatomical  observations — Use  of  the  external  ear — Effect  of  the  removal  of 
the  external  ear  (case) — Pathological  observations — Malformations  of  the 
external  ear,  with  absence  of  the  external  meatus  (cases) — Supernu- 
merary ears — Inflammatory  diseases — Chronic  erysipelas — Chronic  ec- 
zema— Cysts — Tumors — Deposits — Malignant  disease,  ....       42 


CHAPTER  III. 
THE  EXTERNAL  MEATUS. 

ITS    EXPLORATION. 

Anatomical  observations — Osseous  meatus — Membranous  meatus — Objects 
in  exploring  the  meatus — Means  of  exploration — Lamps — Speculum — 
Mode  of  exploration,      ..........       57 

CHAPTER  IV. 
THE  EXTERNAL  MEATUS  {continued). 

ON    FOREIGN   BODIES    AND    ACCUMULATIONS    OF    CERUMEN    IN   THE    MEATUS. 

Foreign  bodies  in  the  meatus — Mode  of  removal — Cases — Ceruminous  glands 
— Their  diseases — Accumulations  of  cerumen — Their  causes — Table  of 
two  hundred  cases  in  which  cerumen  was  removed — Symptoms — Effects 
— Treatment — Mode  of  removal — The  syringe  and  its  use — Cases,         .       GS 


X  CONTENTS. 

CHAPTER  V. 

THE  EXTERNAL  MEATUS  {conilnued). 

THE    DERMIS    AND    ITS    DISEASES. 

PAGE 

1.  Acute  inflammation  : — a,  Acute  inflammation  confined  to  the  dermis — 

Treatment — Cases.  6,  Acute  inflammation  extending  to  the  brain  and 
its  membranes — Treatment — Cases. 

2.  Chronic  inflammation  :  a,  Chronic  inflammation  with  hypertrophy  and  ac- 

cumulation of  epidermis — Treatment — Cases,  b,  Chronic  catarrhal  in- 
flammation— Treatment — Cases.  c,  Chronic  catarrhal  inflammation, 
extending  to  the  bone  and  to  the  brain — Treatment — Cases,  d,  Ulcera- 
tion,      .............       88 

CHAPTER  VI. 

THE  EXTERNAL  MEATUS  {continned). 

POLYPI. 

Causes  of  polypus — Symptoms — Three  species  of  polypus  :  1.  The  cellular 
raspberry  polypus — Structure — Treatment  with  potassa  cum  calce — 
Cases — Treatment  by  removal  with  the  lever-ring  forceps — Cases.  2. 
The  fibro-gelatinous  polypus — Structure — Treatment — Cases.  3.  The 
globular  cellular  polypus — Structure — Treatment — Cases,       .         .         .111 


CHAPTER  VII. 
THE  EXTERNAL  MEATUS  {concluded). 

TUMORS. 

Osseous  tumors — Structui-e — Two  classes — Treatment — Cases — Molluscous 
tumors — Structure — Effects  on  the  bone — Treatment — Case — Conclusion 
of  the  subject  of  the  diseases  of  the  external  meatus — Tabular  view  of 
the  morbid  conditions  found  in  the  meatus  exteruus  in  1013  dissections,     13G 

CHAPTER  VIII. 

THE  MEMBRANA  TYMPANL 

STUVCTURE   AXD   FUXCTIOXS. 

The  epidermoid  layer — The  dermoid  layer — The  fibrous  layers : — The  radiate 
.  fibrous  lavcr — The  circular  fibrous  layer — The  mucous  layer — Tensor  liga- 
ment— Functions  of  the  membrana  tympani,  .         .         .         .         .151 


CONTENTS.  XI 


CHAPTER  IX. 

THE  MEMBRANA  TYMPANI  {continued). 

PAGE 

The  epidermoid  layer — Dermoid  layer — a,  Acute  inflammation — Treatment — 
Cases,  b,  Chronic  inflammation — Cases,  c,  Ulceration — Cases.  Fibrous 
laminae  :  a,  Acute  inflammation,  b,  Chronic  inflammation,  c,  Ulceration. 
d,  Calcareous  degeneration,  e,  Relaxation  of  the  membrana  tympani — 
Treatment — Cases, 164 

CHAPTER  X. 

THE  MEMBRANA  TYMPANI  {concluded). 

Perforation,  causes — Physiological  observations — Experiments  previous  to 
the  formation  of  an  artificial  membrana  tympani  — On  the  artificial 
membrana  tympani — The  mode  of  applying  it — Cases — Rupture  of  the 
membrana  tympani — Physiological  observations — Pathological  observa- 
tions— Cases,  .         .        ^ 18G 

CHAPTER  XL 

THE  EUSTACHIAN  TUBE. 

Anatomical  observations — Physiological  observations — Pathological  observa- 
tions— Seat  of  obstruction  in  the  Eustachian  tube: — 1,  The  faucial  ori- 
fice. 2,  The  tympanic  orifice.  3,  Middle  part. — Causes  of  obstruction  : 
— 1,  Thickened  mucous  membrane.  2,  Relaxed  mucous  membrane,  a, 
Obstruction  of  the  faucial  orifice  from  thickened  mucous  membrane — 
The  exploration  of  the  tube  —  The  otoscope — Treatment — Use  of  the 
Eustachian  catheter  and  of  the  explorer — The  excision  of  the  tonsils — 
Cases.  &,  Obstruction  of  the  Eustachian  tube  at  its  faucial  orifice  from 
relaxed  mucous  membrane — Symptoms — Treatment — Cases,  c,  Obstruc- 
tion of  the  Eustachian  tube  at  the  tympanic  orifice  from  thickened  mucous 
membrane — Symptoms — Treatment — On  the  operation  of  puncturing  the 
membrana  tymj^ani.  d,  Obstruction  of  the  middle  part  of  the  Eustachian 
tube  by  mucus,  by  stricture,  or  by  membranous  bands,  ....     213 


CHAPTER  XII. 

THE  CAVITY  OF  THE  TYMPANUM. 

Anatomical  observations — Pathological  observations — Diseases  of  the  mucous 
membrane  : — a,  Congestion.  b,  Acute  inflammation — Affecting  the 
portio  dura  nei've — Extending  to  the  brain — Scrofulous  matter  in  the 
tympanic  cavity,  c,  Chronic  inflammation.  J,  Chronic  catarrhal  inflam- 
mation, e,  Chronic  catarrhal  inflammation  extending  to  the  bone,  dura 
mater,  or  brain,    yj  Ulceration  of  the  mucous  membrane,       .         .         .     248 


Ml  CONTENTS. 

CHAPTER  XIII. 
THE  CAVITY  OF  THE  TYMPANUM  {concluded). 

Page 
a,  Rigidity  of  the  mucous  membrane — Cause  of  deafness  in  advancing  years — 
Treatment — Cases,  h,  The  formation  of  bands  of  adhesion,  c,  Anchy- 
losis of  the  stapes  to  the  fenestra  ovalis — Pathological  observations — 
Treatment — Cases,  d,  Disconnection  of  the  incus  and  stapes — Physiolo- 
gical observations — Pathological  ob.sf:rvations — Cases,   ....     288 

CHAPTER  XIV. 

THE  MASTOID  CELLS. 

Anatomical  observations — a,  Diseases  of  the  mastoid  cells  in  childhoo^l — 
Cases  of  the  disease  advancing  to  the  bone  and  the  cerebrum.  0,  Diseases 
of  the  mastoid  cells  in  the  adult — Acute  inflammation  of  the  mucous 
membrane — Chronic  inflammation  of  the  mucous  membrane — Purulent 
infection — Symptoms  of  remittent  fever — Caries  of  the  lateral  sulcus — 
Abscess  in  the  cerebellum,  c,  Necrosis  of  the  mastoid  process — Paralysis 
of  the  portio  dura  nerve — Treatment — Opinion  respecting  life  insurance 
in  cases  of  discharge  from  the  ear, 321 

CHAPTER  XV. 

THE  DISEASES  OF  THE  NERVOUS  APPARATUS  OF  THE  EAR, 
PRODUCING  WHAT  IS  USUALLY  CALLED  "NERVOUS  DEAF- 
NESS." 

a.  Diseases  in  which  the  ear  alone  is  affected  : — 1.  From  concussion — Three 
modes — Blows  on  the  ear — Loud  sounds — Falls.  2.  From  the  applica- 
tion of  cold — Cold  air — Cold  water.  3.  From  the  effect  of  morbid  poi- 
sons— Rheumatic  fever — Typhus  fever — .Scarlet  fever — Mumps — Gout. 

h.  Diseases  in  which  the  brain,  as  well  as  the  ear,  is  affected  : — 1.  Mental 
excitement — Over-study — Sorrow.  2.  Bodily  Debility — Want  of  sleep 
— Accouchements — Over-exhaustion  in  hot  climates  —  Fasting — Nen- 
ralgia,    .............     367 

CHAPTER  XVI. 

THE  DISEASES  OF  THE  NERVOUS  APPARATUS  {concluded). 

Ulceration  of  the  membranous  labyrinth — Caries  and  necrosis  of  the  petrous 

bone, 392 


CONTENTS.  Xm 

CHAPTER  XVII. 

MALIGNANT  DISEASE  OP  THE  EAR. 

PAGE 

Origin  in  the  mucous  membrane  of  the  tympanum — Destruction  of  the 
petrous  bone — Sometimes  mistaken  for  polypus — Operations  to  be  avoided 
— Brain  and  dura  mater  involved — Treatment, 404 

CHAPTER  XVIII. 

ON  THE  DEAF  AND  DUMB. 

Diseases  producing  deaf-mutism — The  condition  of  the  ears  in  the  deaf  and 
dumb,  as  ascertained  by  examination  during  life — The  condition  of  the 
ear  in  the  deaf  and  dumb,  as  revealed  by  dissection — The  mode  of  exami- 
ning a  child  supposed  to  be  deaf  and  dumb — On  the  medical  treatment  of 
the  ears  of  the  deaf  and  dumb — The  amount  of  hearing  possessed  by  chil- 
dren usually  accounted  deaf  and  dumb — On  the  education  of  the  deaf  and 
dumb,  with  cases, 413 

CHAPTER  XIX. 
EAR-TRUMPETS  AND  THEIR  USE, 435 

APPENDIX. 

List  of  published  papers  on  the  Structure,  Functions,  and  Diseases  of  the 
Ear, 437 


LIST  OF  ILLUSTRATIONS. 


1.  Cvttiag  Foreeie, 49 

2.  MalfonMdrigktSxtemlEaroraehiU, 4T 

3.  The  i»di»ft»iy  Memtas  Awditotiaa  Bxteiwgof  »  AiM,  ia  the  fiti^rf  a  fawre 

pMtoior  to  the  Coadjkid  Tnxeas, 48 

4.  The  Tjaqpaaie  CkTitj,  with  the  Baalachiaa  tabe  oprmimg  iato  its  aaterior  aad 

jafieriar  part, .41 

3.  Badtoeataiy  Extoaal  Eais .  M 

C.  HcBatoede  of  the  Ezteraal  Ear  (Wilde  .  M 

7.  TaMoroftheLobafefWlMe),     ...  55 

8.  ArerticalsectiflBal'thefcft  MeatasExtexaos,  firABmiihoat  iA«aE\i£,  57 

9.  The  Oiifice  of  the  Meatas  Bxtciaas,  Bhewiag  it>  onal  ihape,      ....  59 
19.  The  Obbhms  Meatas  Bxtcfaas  of  aa  ia&at, M 

11.  The  Mode  of  eaaMiaiag  the  Ear  hy  aid  of  gaaligtrt^ 62 

12.  Mfliex's  l^mp,  o|Ma,  ....  S3 

13.  MiDeT's  LaaiVk  doeed, 63 

14.  A  get  of  Spccala  feg  the  paijwue  rf  eT^Miaiag  the  Bne»aal  Meatai^  65 
13.  The  Sargeea  >»«»i»i»g  the  ExteroAl  3Ie«£iij  hr  means  of  ICIlier**  Lamp  aifi 

the  Tabalar  ^ceala^  66 

16.  Bectaagalar  Foreefe,                                                                 .  T2 

17.  The  Exteiaal  Meatas  gtcatljr  dilated  bj  a  piece  of  cottoa-voolT  73 

18.  CcraMeaiacoatactwiththe  oatcr  sai&ce  of  the  McadbfaaaTjraqnai,  86 

19.  Meatas  greatly  dilated  hjr  etxmmtm, 81 

29.  Aatcnor  wall  of  the  Oaeoas  Meatas  partlj  aheorited,  foDowiag  the  |hi  wan  of 

aa  aecasalatioa  of  cciaaea, 81 

31.  Ccraaea  pttfjcctii^throaghthe  Mealmua  TrBpam  iato  the  Tjvpaaie  Csritj,  82 

23.  Syrii^e  aad  Soxiie, 83 

33.  Ear-spoat,  tkted  oa  the  head, 8ft 

24.  Epidenus  firaa  the  Exteiaal  Meatas  ia  the  foim  of  a  tahalar  cal  de  gac,  aad  a 

lajer  anaagcd  cirealaiiy, 9T 

35.  The  latoaal  Sai&ce  of  the  Teapofal  Boae,  Aaaiag  two  oiifc.**  la  the  Lateral 

Siaas,  filed  hj  ttramtm :  aad  also  the  caiioas  Saleas  LatenliB,  .                 .  165 

36.  The  Exteiaal  SaiCace  of  the  Temporal  Boae,  Aorwi^  a  caxioai  po»tii«  cxtead- 

ii^  &oai  the  Mastoid  Procea  to  the  loot  of  the  Zjgoaatie  Plroces.  196 

27.  Baspheny  CeOalar  Poljpas, 112 

28.  C^alar  straetaie  of  the  Ba^heny  Peljpasy 113 

29.  A  large  Baspheny  Poljpas,  Tiable  at  the  oeifiec  of  the  Meatas,  113 
39.  TheSaareofMr.  WOde, .  119 

31.  The  Lerer-riag  Forceps,  opea, 119 

32.  The  Lerer-riag  Fotccpo  holdiag  a  Polypas, 131 

33.  FiW»-gelatiBoas  Paijpw, 133 


LIST     OF    ILLUSTRATIONS. 


XV 


FIO. 

34.  Structure  of  the  Fibro-gelatinous  Polypus, 

35.  The  Ring  Forceps 

36.  Globular  Cellular  Polypus, 

37.  Two  Osseous  Tumors  projecting  from  the  walls  of  the  Meatus  Externus,     . 

38.  The  vertical  section  of  the  External  Meatus  and  Osseous  Tumor, 

39.  Three  Osseous  Tumors  projecting  from  the  walls  of  the  Meatus, 

40.  A  large  Osseous  Tumor  and  two  smaller  ones  in  the  Meatus  Externus, 

41.  Two  Osseous  Tumors  of  the  External  Meatus  in  contact  internally,     . 

42.  An  Osseous  Tumor  growing  from  the  Upper  Wall  of  the  Meatus, 

43.  Osseous  Matter  developed  from  the  walls  of  the  Meatus  Externus, 

44.  Molluscous  Tumor  filling  the  whole  of  the  Meatus  Externus,       .         .  .         . 

45.  Cavity  in  the  Meatus  Externus  from  which  a  Molluscous  tumor  has  been  removed, 

46.  Apertures  in  the  upper  wall  of  the  Meatus  Externus  communicating  with  the 

Cerebral  Cavity,  produced  by  a  Molluscous  Tumor,       .... 

47.  The  Triangular  Shining  Spot  at  the  anterior  and  inferior  part  of  the  surface  o 

the  Membrana  Tympani,        ......... 

^8.  The  Dermoid  Layer  of  the  Membrana  Tympani  continuous  with  the  Dermis  lining 
the  upper  wall  of  the  Meatus  Externus,  ...... 

49.  The  Radiate  Fibrous  Layer  of  the  Membrana  Tympani,      .... 

50.  The  Fibres  composing  the  Radiate  Fibrous  Lamina  (magnified), 

51.  The  Radiate  Fibrous  Lamina, 

52.  The  Radiate  Fibrous  Lamina,  after  having  been  treated  with  Acetic  Acid, 

53.  The  Circular  Cartilaginous  Band,  after  having  been  treated  by  Acetic  Acid, 

54.  The  External  Surface  of  the  Circular  Fibrous  Lamina  (slightly  magnified), 

55.  The  Internal  Surface  of  the  Circular  Fibrous  Lamina  (slightly  magnified), 

56.  The  Fibres  composing  the  Circular  Fibrous  Lamina,  ..... 

57.  The  Fibres  of  the  Circular  Fibrous  Lamina,  treated  with  Acetic  Acid, 

58.  The  Radiate  Fibrous  Lamina,  the  Circular  Fibrous  Lamina,  and  the  Mucous 

Membrane  of  the  Membrana  Tympani  (slightly  magnified),  . 

59.  The  Attachments  of  the  Tensor  Tympani  Ligament  (slightly  magnified),    . 

60.  Epidermoid  Layer  of  the  Membrana  Tympani  hypertrophied  (magnified),  . 

61.  Granulations  on  the  surface  of  the  Dermoid  Layer  of  the  Membrana  Tympani 

62.  The  Membrana  Tympani  fallen  in  towards  the  Promontory  (seen  in  section), 

63.  The  Membrana  Tympani  fallen  in  towards  the  Promontory  (seen  from  without), 

64.  An  Orifice  in  the  Membrana  Tympani  produced  by  ulceration  of  the  Fibrous 

Laminae,        ............. 

65.  The  Fibrous  Layers  of  the  Membrana  Tympani  ulcerated  over  a  small  extent  at 

its  anterior  part,    ............ 

66.  Calcareous  Deposit  in  the  Circular  Fibrous  Lamina  of  the  Membrana  Tympani, 

67.  Calcareous  Deposit  in  the  Radiate  Fibrous  Lamina  of  the  Membrana  Tympani, 

68.  The  whole  of  the  Membrana  Tympani  converted  into  Calcareous  Matter,   . 

69.  The  Artificial  Membrana  Tympani,     ......... 

70.  Margin  of  the  circumference  of  the  Membrana  Tympani  remaining  after  the 

destruction  of  the  rest  of  the  membrane,         ....... 

71.  Handle  of  the  Malleus  remaining  after  the  destruction  of  the  Membrana  Tympani, 

72.  Body  of  Malleus  remaining  after  destruction  of  Membrana  Tympani, 

73.  Surgeon  introducing  the  Artificial  Membrana  Tympani, 

74.  An  Aperture  in  the  lower  part  of  the  left  Membrana  Tympani,  from  rupture, 

75.  An  Aperture  in  the  posterior  part  of  the  right  Membrana  Tympani,  from  rupture, 

76.  An  Aperture  in  the  right  Membrana  Tympani, 

77.  The  Otoscope, 

78.  The  Surgeon  using  the  Oto.«cope,         ......... 

79.  The  Explorer,  and  the  Eustachian  Catheter  into  which  it  fits,    .         .         .         . 


PAGE 

124 
126 
130 
136 
137 
141 
141 
143 
144 
145 
148 
148 

149 

152 

153 
155 
156 
156 
157 
157 
158 
159 
159 
160 

160 
161 
164 
171 
175 
176 

176 

177 
179 
179 
180 
191 

191 
192 
193 
194 
208 
209 
210 
221 
222 
227 


X\n  LIST    OF    ILLUSTRATIONS. 

FIG.  PAGE 

80.  The  Surgeon  using  the  Eustachian  Catheter  and  the  Explorer,   ....  228 

81.  Stricture  of  the  Eustachian  Tube 247 

82.  An  antero-posterior  vertical  section  of  the  Temporal  Bone  through  the  Tympa- 

nic Cavity  and  Mastoid  Cells, 249 

83.  The  upper  Osseous  Wall  of  the  Tympanum  defective, 250 

84.  The  Canal  for  the  Portio  Dura  Nerve  at  the  upper  part  of  the  Tympanic  Cavity 

incomplete,    .............  260 

85.  The  Internal  Surface  of  the  Temporal  Bone,  the  Tympanic  Cavity  diseased,        .  283 

86.  The  lower  Osseous  Wall  of  the  Tympanum  incomplete 286 

87.  The  Orifice  seen  from  the  Jugular  Fossa 286 

88.  Membranous  Bands  connecting  the  Ossicles,        .         ......  295 

89.  Membranous  Bands  connecting  the  Ossicles  to  the  Promontory  (magnified),        •  296 

90.  The  whole  of  the  Circumference  of  the  base  of  the  Stapes  anchylosed  to  the 

Fenestra  Ovalis,  the  Crura  detached, 299 

91 .  Base  of  the  Stapes  expanded,  and  osseous  matter  thrown  around  it  and  the  Crura,  299 

92.  Expansion  of  the  base  of  the  Stapes,  and  its  protrusion  into  the  cavity  of  the 

Vestibule  (magnified),    ...........  300 

93.  Expansion  of  the  Vestibular  Surface  of  the  Articulation  (magnified),          .         .  300 

94.  The  External  Surface  of  the  Temporal  Bone  of  a  child, 322 

95.  A  Vertical  Section  of  the  Temporal  Bone  of  a  child  through  the  horizontal  por- 

tion of  the  Mastoid  Cells,       323 

96.  The  External  Surface  of  the  Temporal  Bone,  showing  the  irregular-shaped  carious 

portion  of  bone  above  the  Meatus,          ........  326 

97.  A  Vertical  Section  of  the  Diseased  Bone,    .         .         .     •    .         .         .         .         .  327 

98.  The  right  Petrous  Bone,  showing  the  carious  condition  of  the  Sulcus  Lateralis,  346 

99.  Caries  of  the  External  Semicircular  Canal,           .......  398 

]nn.  Carious  Temporal  Bone, 409 


THE  DISEASES  OF  THE  EAR. 


CHAPTER     I. 

INTRODUCTION. 

NEGLECT  OF  THE  STUDY  OP  THE  MORBID  ANATOMY  OF  THE  EAR,  THE  CAUSE  OF  OUR 
IGNORANCE  OF  AURAL  SURGERY — MODE  OP  INVESTIGATING  THE  DISEASES  OF  THE 
EAR — METHOD  OF  DISSECTING  THE  EAR. 

As  introductory  to  this  work  on  the  Diseases  of  the  Ear,  I  may  be 
pardoned  the  observation,  that  the  subject  has  hitherto  been  too 
much  regarded,  by  the  great  mass  of  the  profession,  as  a  blank  in 
Medical  Science  ;  indeed,  to  quote  from  Mr.  Wilde's  introduction 
to  his  valuable  treatise  on  Aural  Surgery,  medical  men  are  too 
ready  to  affirm  that  "  they  know  nothing  about  the  diseases  of  the 
organ  of  hearing  ;"  and  many,  looking  upon  the  difficulties  that 
surround  the  investigation  as  insurmountable,  have  tacitly  aban- 
doned its  pursuit.  Yet,  if  we  carefully  survey  the  history  of  the 
rise  and  progress  of  Aural,  as  a  distinct  branch  of  Scientific  Sur- 
gery, one  main  cause  of  the  disrepute  into  which  it  had  fallen  may 
be  traced  to  the  neglect  of  the  pathology  of  the  organ  of  hearing — 
a  neglect  that  doubtless  led  also  to  the  ignorance  which  has  pre- 
vailed as  to  the  structure  and  functions  of  some  of  the  most  impor- 
tant of  its  parts. 

It  is  a  question,  however,  Avhether  the  inherent  difficulties  of 
Aural  Surgery  arc  of  a  nature  to  prevent  its  being  as  thoroughly 
understood  as  the  other  branches  of  surgery.  This  question  has 
been  answered  in  the  affirmative  by  some,  on  the  ground  of  the  deep 
and  hidden  situation  of  the  larger  part  of  the  organ,  and  the  extreme 

3 


34  THE     DISEASES     OF    THE    EAR. 

intricacy  of  its  structure.  But  surely  the  organ  of  hearing  is  not 
so  much  concealed  from  view  as  several  others  (the  heart,  for  in- 
stance), of  whose  diseases  "we  have  a  very  clear  knowledge  ;  nor  is 
its  structure  more  complicated  than  that  of  the  eye.  The  result  of 
my  own  experience,  and  I  think  also  of  those  who  have  carefully 
attended  to  my  practice  at  St.  Mary's  Hospital,  is,  that  the  diseases 
of  the  ear  are  not  more  difficult  to  diagnose,  nor  are  they  on  the 
whole  less  amenable  to  treatment,  than  those  of  the  eye,  the  joints, 
or  almost  any  other  organ  that  can  be  named. 

When  my  attention  was  first  turned  to  the  study  of  the  diseases  of 
the  ear,  I  resolved  to  prosecute  researches  into  the  pathology  of 
the  organ.  From  that  time  to  the  present,  I  have  made  nearly  2000 
dissections  ;  and  although  it  must  be  manifest  that  this  number  is 
small,  compared  to  that  which  is  required  for  the  thorough  elucida- 
tion of  the  subject,  still  I  feel  it  is  a  sufficiently  solid  foundation 
upon  which  to  build  a  rational  system  of  Aural  Surgery. 

Fully  a}vare  of  the  difficulties  in  the  way  of  procuring  specimens 
from  those  deaf  persons  who  had  been  inspected  during  life,  and 
whose  histories  had  been  recorded,  I  determined  at  once  to  dissect 
every  ear  that  I  could  obtain,  in  order  to  ascertain  Avhat  arc  the 
most  common  morbid  conditions  to  which  the  organ  of  hearing  is 
subject ;  in  fact,  to  secure  one  step  first,  by  ascertaining  something 
of  the  morbid  anatomy  of  the  ear,  before  advancing  to  a  consideration 
of  its  pathology.  The  result  of  my  investigations  established  this 
general  fact,  that  the  existence  of  some  of  the  most  important  affec- 
tions of  the  ear  had  not  even  been  imagined.  Having  advanced 
thus  far  with  the  morbid  anatomy  of  the  ear,  my  next  step  was  to 
pursue  its  pathology.  This  was  effected,  in  the  first  place,  by  prose- 
cuting inc^uiries  into  the  history  of  the  patients  whose  ears  were 
found  to  be  diseased  ;  secondly,  by  dissecting  the  ears  of  deaf  per- 
sons supplied  to  me  by  medical  men,  and  comparing  the  morbid 
appearances  observed  with  the  notes  accompanying  the  cases  ;  and 
thirdly,  by  availing  myself  of  the  opportunity,  during  some  years, 
of  inspecting  all  the  ;leaf  persons  in  an  institution  containing  more 
than  2000.  individuals,  of  recording  their  cases,  and  then  of  making 
dissections  of  the  organ  of  hearing  in  those  who  died.  By  these 
means,  and  by  the  facilities  offered  at  the  public  institutions  to  which 
I  have  been  attached,  of  conducting  post-mortem  inspections  of  the 
patients  attended  by  me,  I  have  been  able  in  many  cases  to  compare 
the  symptoms  occurring  during  life,  the  appearances  of  the  organ. 


INTRODUCTION'.  35 

and  the  history  of  the  case,  with  the  morbid  structures  found  after 
death. 

3Iode  of  investigating  the  Diseases  of  the  Ear. — The  following 
plan  for  eliciting  all  the  important  particulars  with  which  a  surgeon 
ou^ht  to  be  acquainted  Avhen  endeavering  to  form  a  diagnosis  of  dis- 
ease of  the  ear,  has  been  pursued  by  me  during  many  years.  Its 
use  involves  no  great  time  or  labor  ;  and  as  it  is  desirable  that  it 
should  be  observed  by  those  studying  the  subject,  I  will  describe  it 
in  detail. 

I.  The  age  and  occupation  of  patient. 
II.  State  of  health,  temperament,  condition  of  pulse,  &c. 

III.  If  any  relations  are  deaf,  name  them. 

IV.  History  of  the  affection  ;  duration  ;  supposed  cause.  Former 
symptoms :  if  at  any  time  pain  in  the  ears  or  head.  Nature  of  jyro- 
gress  :  whether  rapid  or  slow  ;  if  it  has  increased  by  sudden  parox- 
ysms, or  by  imperceptible  degrees.  Present  symptoms  :  if  pain, 
noises,  or  discharge  ;  amount  of  hearing  power  as  shown  by  conver- 
sation ;  whether  the  patient  require  to  be  spoken  to  distinctly  in  a 
room,  or  within  the  distance  of  a  yard,  or  close  to  the  ear  :  which 
ear  is  the  worse.  Causes  aggravating  the  deafness  :  a  cold,  cold  or 
moist  weather,  bodily  fatigue  or  mental  excitement,  the  act  of  mas- 
tication. Causes  producing  imp)rovement :  improved  health,  dry 
air,  a  cold,  cold  weather,  warm  weather. 

V.  Result  of  examination. 

Right  ear.     The  distance  at  which  the  watch  is  heard. ^ 

3Ieatus  :  quantity  and  condition  of  the  cerumen  ;  state  of  the 
dermis  and  of  the  osseous  wall. 

Memhrana  tympani :  surface  dull  or  shining,  transparent  or 
opaque,  state  of  the  triangular  bright  spot ,  if  more  or  less  concave 
than  natural. 

Eustachian  tube  :  if  air  is  heard  by  means  of  the  otoscope  to  enter 
the  tympanic  cavity  naturally  during  deglutition,  the  nose  and  mouth 
being  closed  ;  if  the  air  is  heard  to  enter  the  tympanic  cavity  natu- 
rally during  a  forcible  attempt  at  expiration  with  the  nose  and  mouth 
held  closed. 

Left  ear  :  ditto.     State  of  mucous  membrane  of  the  fauces. 


'  The  medical  man  should  ascertain  the  distance  at  which  his  watch  is  usually  heard  by 
persons  whose  hearing  power  is  supposed  to  be  perfect.  The  hearing  distance  with  mj- 
own  watch  is  about  three  feet.  The  wiitch  should  be  gradually  brought  towards  the  ear 
instead  of  being  withdrawn  from  it. 


36  XnEDISEASESOFTHEEAR. 

VI.  Previous  treatment. 

VII.  Diagnosis. 

Although  this  enumeration  of  all  the  points  Avhich  require  filling 
up,  might  lead  to  the  idea  that  the  use  of  this  i)laii  must  be  attended 
■with  considerable  trouble  in  actual  practice,  it  will  be  found  other- 
wise, as  numerous  abbreviations  may  be  resorted  to.  For  example, 
take  the  following  case. 

F.  R.,  set.  43,  architect.  H.  (health) :  tolerable,  but  subject  to 
attacks  of  sore  throat.  R.  D.  (relations  who  are  deaf) :  A  brother 
and  sister  were  both  deaf  when  young,  but  quite  recovered  before 
reaching  the  age  of  20. 

H.  (history)  :  "When  a  boy,  suffered  from  ear-ache,  which  was 
often  followed  by  deafness  and  sometimes  by  discharge  from  each 
ear.  Subsequently  the  attacks  of  ear-ache  ceased;  but  he  has  ever 
since  been  subject  to  fits  of  deafness  which  have  usually  come  on 
durin<T  an  attack  of  cold,  and  have  lasted  for  periods  varying  from 
two  to  several  weeks.  During  the  attacks,  the  power  of  hearing  has 
been  so  much  diminished,  that  he  could  only  hear  a  loud  voice  when 
within  the  distance  of  half  a  yard.  Each  attack  has  usually  disap- 
peared with  the  occurrence  of  a  sudden  crack  in  the  ear.  The  pre- 
sent attack  came  on  six  months  ago,  after  a  bad  cold ;  it  has  been 
slightly  relieved  on  one  or  two  occasions,  but  the  deafness  speedily 
returned.  At  the  present  time  he  requires  to  be  spoken  to  in  a  loud 
voice  within  a  yard  of  the  ears,  and  there  is  a  constant  singing  with 
a  sensation  of  pressure  in  them,  and  a  feeling  as  of  weight  on  the 
head.  P.  T.  (previous  treatment) :  The  application  of  glycerine  to 
the  meatus  ;  syringing  with  warm  water  ;  blisters  behind  the  ears  ; 
the  use  of  the  Eustachian  catheter  and  a  pump  over  the  ears,  all 
without  benefit.  R.  E.  (right  ear) :  M.  E.  (meatus  externus)  con- 
tained cerumen  in  a  normal  (juantity  and  consistence.  M.  T.  (mem- 
brana  tympani) :  Outer  surface  glassy  ;  the  bright  spot  more  elon- 
gated tlian  natural,  and  somewhat  striated  ;  the  membrane  of  a 
leaden  hue,  and  much  more  concave  than  natural.  E.  T.  (Eusta- 
chian tube) :  No  air  is  heard  to  enter  either  during  the  act  of  swal- 
lowing or  during  a  forcible  expiration  with  closed  mouth  and  nose, 
neither  does  the  patient  feel  any  sensation  in  the  ears,  nor  is  the 
membrana  tympani  seen  to  move  during  these  operations.  II.  D. 
(hearing  distance):  Contact.  L.  E.  (left  ear) :  the  same  as  the  right, 
except  that  the  membrana  tympani  is  somewhat  opaque.  The  watch 
is  only  heard  when  pressed  upon  the  ear. 


INTRODUCTION.  37 

The  mucous  membrane  of  the  fauces  is  red  and  spongy,  and  much 
thicker  than  natural ;  and  each  tonsil  is  somewhat  enlarged. 

D.  (diagnosis) :  Occlusion  of  the  faucial  orifice  of  each  Eustachian 
tube  bj  thickened  mucous  membrane.  The  grounds  for  forming  this 
diagnosis  are : — 

Firstly.  The  history  of  the  case,  the  constitution  of  the  patient, 
the  peculiar  similar  attacks  which  had  occurred  to  a  brother  and 
sister,  and  especially  the  sudden  attacks  of  deafness  following  a 
cold,  and  their  sudden  disappearance  after  a  crack,  the  latter  being 
caused  by  the  sudden  entrance  of  the  air  into  the  tympanic  cavity, 
and  the  return  of  the  membrana  tympani  to  its  natural  position. 

Secondly.  The  concave  condition  of  the  membrana  tympani, 
■which  showed  that  there  was  very  little  air  in  the  tympanic  cavity, 
while  there  was  no  history  of  other  disease  to  cause  the  concavity. 
The  reason  for  assuming  that  the  obstruction  was  at  the  faucial  and 
not  at  the  tympanic  orifice,  was  the  fact  that  the  membrana  tym- 
pani was  translucent  in  one  ear,  and  only  slightly  opaque  in  the 
other  ;  whereas,  an  amount  of  inflammation  sufiicient  to  cause  ob- 
struction at  the  tympanic  orifice  of  the  tube,  would  necessarily  be 
attended  by  considerable  thickening  of  the  mucous  membrane 
lining  the  inner  surface  of  the  membrana  tympani,  and  produce 
great  opacity. 

Thirdly.  The  condition  of  the  mucous  membrane  of  the  fauces, 
and  the  result  of  the  exploration  of  the  tube  by  means  of  the  oto- 
scope. 

T.  (treatment) :  The  object  is  to  reduce  the  mucous  membrane 
covering  the  orifices  of  the  tubes  to  a  natural  condition,  so  that  the 
muscles  may  be  enabled  to  open  them.  For  this  purpose  the  solid 
nitrate  of  silver  was  applied  to  the  mucous  membrane  of  the  fauces 
twice  a  week,  and  an  astringent  gargle  was  also  used ;  small  doses 
of  quinine  and  colocynth  were  administered  each  night.  The  sur- 
face of  the  body  was  directed  to  be  rubbed  daily  with  a  towel  dipped 
in  cold  water,  and  abundant  exercise  on  foot  was  recommended. 

The  result  of  this  treatment  was  to  produce  some  slight  improve- 
ment in  the  course  of  the  first  Aveek  ;  in  the  course  of  the  second,  a 
crack  took  place  in  the  right  ear,  which  was  followed  by  a  perfect 
restoration  of  the  hearing  in  that  organ  ;  the  air  Avas  then  heard  to 
enter,  upon  slightly  forcing  it ;  but  it  did  not  yet  find  its  Avay  during 
the  act  of  deglutition.  In  the  course  of  a  day  or  two  the  left  ear 
also  improved  greatly,  though  not  equally  with  the  right.    This  may 


38  TIIEDISEASESOFTHEEAR. 

be  accounted  for  by  the  thickened  state  of  the  mucous  membrane  of 
the  tympanum  on  that  side. 

Now  the  case  just  cited  is  ilhistrative  of  a  large  proportion  of  the 
cases  met  with  in  the  practice  of  Aural  Surgery.  I  mean,  that  in 
most  cases,  by  a  careful  attention  to  the  history,  aided  by  an  effi- 
cient examination  of  the  organ,  a  medical  man  can  form  a  tolerably 
accurate  diagnosis.  It  has  often  been  asked,  how  is  it  possible  to 
diagnose  between  anchylosis  of  the  stapes  and  nervous  deafness,  two 
cases  in  which  perhaps  no  disease  of  the  organ  is  apparent  ?  But 
the  history  of  the  origin  and  progress  of  the  cases,  the  nature  of  the 
patients'  constitution,  and  the  symptoms  of  the  diseases,  are  quite 
sufficient  to  remove  any  difficulty  on  the  subject.  Indeed,  so  much 
is  capable  of  being  learned  from  the  history  of  a  case,  that  very 
often  a  pretty  accurate  diagnosis  may  be  formed  without  ocular  in- 
spection. For  instance,  in  the  above  case  my  mind  was  made  up  as 
to  its  nature  before  making  any  examination.  Again,  the  condition 
of  the  Eustachian  tube  is  to  be  learnt  by  the  state  of  the  membrana 
tympani.  "When  this  tube  is  obstructed,  the  air  that  was  contained 
in  the  tympanic  cavity  disappears,  in  part,  in  the  course  of  a  few 
hours,  either  from  absorption  or  exosmosis.  The  effect  of  this  par- 
tial disappearance  of  the  air  from  the  tympanic  cavity  is,  that  the 
membrana  tympani  becomes  drawn  inwards  and  very  concave  exter- 
nally ;  and  although  this  peculiar  condition  of  the  membrana  tym- 
pani is  met  with  in  other  diseases  of  the  ear,  their  history  differs 
from  that  of  simple  obstruction  of  the  Eustachian  tube. 

My  object  in  citing  the  foregoing  case  has  been  to  show  that  after 
carefully  collecting  the  history  of  a  case,  and  making  a  thorough 
inspection  of  the  organ,  there  is  generally  not  much  difficidty  in 
forming  a  tolerablv  correct  diagnosis. 

Method  of  dissecting  the  ear. — In  concluding  these  introductory 
observations,  I  will  give  some  directions  respecting  the  mode  of  re- 
moving and  dissecting  the  petrous  bone. 

The  simplest  method  of  removing  the  ears  for  the  sake  of  dissec- 
tion, is,  in  the  first  place,  to  saw  off  the  calvaria  in  the  usual  way, 
and  then  to  take  out  both  the  petrous  bones  together,  by  means  of 
two  transverse  vertical  sections,  one  in  front  of  the  two  petrous 
bones  and  tlie  other  posterior  to  tliem.  The  anterior  of  tliese  sec- 
tions should  pass  in  a  line  a  little  anterior  to  the  anterior  clinoid 
processes,  and  the  posterior  in  a  line  through  the  posterior  third  of 
each  mastoid  process.    By  means  of  these  two  sections,  the  trumpet- 


INTRODUCTION.  39 

shaped  extremity  of  each  Eustachian  tube,  a  portion  of  the  raucous 
membrane  of  the  fauces,  and  the  Avhole  of  each  petrous  bone,  toge- 
ther with  the  mastoid  processes,  can  be  taken  out.  The  disadvan- 
tage of  this  procedure  is  the  disfigurement  which  is  apt  to  ensue 
from  the  falling  in  of  the  face.  To  avoid  this  disadvantage  another 
mode  of  removing  the  cars  may  be  resorted  to  ;  this  consists  in 
taking  out  each  petrous  bone  separately  in  the  following  manner: — 
The  calvaria  having;  been  sawn  oif,  an  anterior  section  is  to  be  made 
on  each  side  on  the  same  line  as  in  the  above  plan,  but  extending 
only  as  far  as  the  outer  part  of  the  body  of  the  sphenoid  bone  ;  a 
posterior  section  on  each  side  is  then  to  be  made,  as  in  the  first  plan, 
but  not  extending  further  inwards  than  the  basilar  process  of  the 
occipital  bone.  These  two  sections  are  to  be  made  with  a  saw,  or 
with  a  chisel  and  hammer ;  the  apex  of  each  petrous  bone  is  then  to 
be  separated  from  the  sphenoid  and  occipital  bones,  and  each  petrous 
bone  (the  outer  ear  and  integument  being  detached  and  reflected 
dowuAvards)  is  to  be  drawn  outwards,  taking  care,  by  inserting  the 
scalpel  deeply,  to  remove  as  much  of  the  soft  parts  as  possible. 
With  this  second  plan  there  is  a  difiiculty  in  removing  the  whole  of 
the  guttural  portion  of  the  Eustachian  tube ;  with  care,  however,  this 
portion  may  be  removed,  especially  if  the  final  sections  separating 
the  petrous  bone  from  the  occipital  and  sphenoid  be  made  to  pass 
obliquely  from  above,  downwards,  and  inwards.  The  organ  of  hear- 
ing having  been  removed,  the  dissection  may  be  conducted  in  the 
following  manner  : — The  auditory  nerve  in  its  meatus  should  be  first 
carefully  examined,  premising  that,  a  previous  inspection  has  been 
made  of  the  portion  of  the  brain  to  which  the  portio  mollis  and 
portio  dura  nerves  are  attached.  The  size  of  the  external  meatus 
having  been  ascertained  by  allowing  a  strong  light  to  fall  into  it,  its 
anterior  wall  is  to  be  removed  by  the  cutting  forceps,  made  by 
Messrs.  Ash,  of  Broad  Street,  Golden  Square ;  the  state  of  the  epi- 
dermis, the  ceruminous  glands,  and  secretion,  the  dermis,  perios- 
teum, and  bone,  are  to  be  noticed.  The  outer  surface  of  the  mem- 
brana  tympani  is  then  to  be  examined ;  also  the  state  of  its  epider- 
moid and  dermoid  laminae,  its  degree  of  tension,  and  the  amount  of 
motion  possessed  by  the  malleus  when  pressed  upon  by  a  fine  point. 
The  next  step  is  to  ascertain  the  condition  of  the  guttural  portion 
of  the  Eustachian  tube,  to  lay  open  the  cartilaginous  tube  with  the 
scissors,  and  then  to  expose  the  cavity  of  the  osseous  portion  by 
means  of  the  cutting  forceps.     In  doing  this,  the  tensor  tympani' 


40  THE    DISEASES    OF    THE    EAR. 

muscle  is  exposed  ;  its  structure  should  be  examined,  and,  if  it  has 
not  a  healthy  appearance,  portions  of  it  should  be  submitted  to  mi- 
croscopic inspection.     The  upper  wall  of  the  tympanum  is  next  to 

Fig.  1. 


Cutting  Forceps. 

be  cut  away,  by  means  of  the  cutting  forceps ;  in  doing  this,  great 
care  must  be  taken  not  to  disturb  or  disconnect  the  malleus  and 
incus,  which  lie  immediately  beneath  it.  After  the  tympanic  cavity 
has  been  exposed,  the  first  step  is  to  pull  the  tensor  tympani  muscle, 
and  to  ascertain  how  far  it  causes  a  movement  of  the  membrana 
tympani  and  ossicles.  The  incus  and  stapes  are  now  to  be  touched 
with  a  fine  point,  so  as  to  ascertain  their  degree  of  mobility ;  the 
tendon  of  the  stapedius  muscle  is  also  to  be  pressed  upon.  The 
condition  of  the  mucous  membrane  of  the  tympanum,  and  of  the 
mastoid  cells,  is  then  to  be  ascertained,  and  any  peculiarity  of  the 
cavity,  the  existence  of  bands  of  adhesion,  &c.,  to  be  noted.  The 
most  delicate  part  of  the  dissection,  viz.,  that  of  the  internal  ear, 
must  now  be  undertaken.  The  cavities  of  the  vestibule  and  cochlea 
are  to  be  exposed,  by  removing  a  small  portion  of  the  upper  wall 
of  each.  Before  reaching  the  vestibule,  the  superior  semicircular 
canal  will  be  cut  through  and  removed;  the  membranous  canal  should 
be  drawn  out  and  inspected.  As  the  cavities  of  the  vestibule  and 
cochlea  arc  laid  l)are,  it  is  desirable  to  see  that  the  (quantity  of  peri- 
lymph is  natural,  as  well  as  its  color  and  consistence.     The  outer 


INTRODUCTION.  41 

surface  of  the  membranous  labyrinth  having  been  observed,  it  should 
be  opened  so  as  to  expose  the  endolymph  and  otoconia,  portions  of 
all  which  parts  should  be  removed  for  microscopic  inspection.  This 
having  been  effected,  the  remaining  membranous  semicircular  canals 
are  to  be  exposed,  and  the  connection  of  the  base  of  the  stapes  to 
the  fenestra  ovalis  carefully  examined.  The  last  stage  of  the  dis- 
section consists  in  removing  parts  of  the  lamina  spiralis,  in  examin- 
ing them  microscopically,  and  in  exposing  from  within,  by  following 
the  course  of  the  scala  tympani,  the  membrane  of  the  fenestra 
rotunda.  The  only  organ  which  now  remains  unexamined,  is  the 
stapedius  muscle  :  in  order  to  expose  it,  the  course  of  the  aquse- 
ductus  Fallopii,  beginning  at  the  stylo-mastoid  foramen,  should  be 
followed  until  the  base  of  the  pyramidal  eminence,  containing  the 
muscle,  is  reached. 


CHAPTER   II. 

THE     EXTERNAL    EAR. 

ANATOMICAL    OBSERVATIONS USE    OF    THE    EXTERNAL    EAR EFFECT    OF    THE    REMOVAL 

OF    THE    EXTERNAL    EAR    (CASE) PATHOLOGICAL    OBSERVATIONS — MALFORMATIONS    OF 

THE  EXTERNAL  EAR,  WITH  ABSENCE  OF  THE  EXTERNAL  MEAT0S  (CASES) — SUPER- 
NUMERARY EARS — INFLAMMATORY  DISEASES — CHRONIC  ERYSIPELAS — CHRONIC  EC- 
ZEMA— CYSTS — TUMORS — DEPOSITS — MALIGNANT    DISEASE. 

Anatomical  Observations. — The  external  ear  is  not  unfre- 
qucntly  described  as  a  portion  of  the  external  auditory  meatus. 
There  arc,  however,  peculiarities  in  the  structure,  functions,  and  dis- 
eases of  these  two  divisions  of  the  ear,  that  render  it  desirable  for 
them  to  be  considered  separately.  The  external  ear,  comprising 
under  that  name  all  parts  of  the  organ  external  to  the  meatus,  is 
placed  between  the  articulation  of  the  lower  jaw  and  the  mastoid 
process,  and  consists  of  a  basis  of  resilient  cartilage,  covered  by 
common  integuments,  the  two  being  connected  by  firm  cellular  tissue! 
On  the  outer  surface  of  the  ear,  the  intciiuments  are  so  firmlv  at- 
tached  to  the  cartilage  that  it  is  difficult  to  draw  them  apart,  or 
even  to  move  the  one  upon  the  other.  The  skin  of  the  ear  is  so 
abundantly  supplied  with  bloodvessels  that  a  dried  specimen  I  pos- 
sess, injected  with  size  and  vermilion,  has,  at  first  sight,  the  appear- 
ance of  a  mass  of  coloring  matter,  which,  upon  minute  examination, 
is  found  to  depend  upon  its  vessels,  that  form  a  very  dense  network 
throughout  every  part.  The  lobule  of  the  ear  consists  of  a  fold  of 
integuments,  Avhich  contains  cellular  tissue  and  a  small  quantity  of 
adipose  matter.  The  cartilage  presents  externally  several  depres- 
sions and  elevations  ;  it  forms  the  concha,  the  large  concavity  look- 
ing obli(juely  outwards  and  forwards,  and  bounded  in  front  by  the 
triangular  projection  called  the  tragus,  which  looks  obliquely  in- 
wards and  backwards,  facing  the  concha.  Posterior,  and  slightly 
inferior  to  the  tragus,  is  the  antitragus.     Extending  upwards  from 


THE     EXTERNAL     EAR.  43 

the  latter  is  the  antihelix,  which  forms  the  rounded  curved  projec- 
tion of  the  outer  ear,  and  divides  above  and  in  front  into  two 
branches  :  of  which  the  inferior  and  more  prominent  terminates 
under  the  helix,  by  which  it  is  concealed;  while  the  superior  branch 
is  very  rounded,  and  seems  as  if  it  were  the  continimtion  of  the  anti- 
helix.  Between  the  tAvo  branches  is  a  fossa,  called  the  fossa  inno- 
minata,  or  the  fossa  of  the  antihelix.  The  helix  is  the  curved  ridge 
which  forms  the  posterior  and  superior  boundary  to  the  ear  :  it 
commences  in  the  cavity  of  the  concha,  which  it  divides  into  two 
parts,  the  inferior  being  the  larger,  and  passes  obliquely  forwards 
and  upwards  above  the  tragus  ;  then  curving  backwards  and  down- 
wards, it  is  continuous  inferiorly  with  the  lobule.  Above  the  tragus, 
the  helix  usually  consists  of  a  flat  band  of  cartilage,  the  inner  sur- 
face being  applied  against  the  superior  branch  of  the  antihelix,  and 
the  superior  part  of  the  concha.  This  arrangement  of  the  helix 
screens  a  portion  of  the  integuments  beneath  it  from  view  and  from 
contact  with  the  air.  This  portion  ought  to  be  carefully  cleansed 
and  dried,  especially  in  children.  In  some  persons,  the  helix  is 
absent ;  and  in  certain  cases  of  malformation  there  is  no  cartilage 
in  the  external  ear. 

Use  of  the  External  Ear. — Opposite  opinions  have  been 
entertained  respecting  the  influence  of  the  external  ear  upon  the 
hearing  power,  Itard  denied  that  it  was  of  any  use,  while  others 
have  considered  that  it  is  of  very  material  service  in  collecting  the 
sonorous  vibrations,  and  in  conducting  them  to  the  meatus.  Riche- 
rand  says  that  the  external  ear  may  be  removed  without  deafness 
being  the  consequence ;  "  For  a  few  days  after  the  loss,  the  hearing 
is  rather  hard,  but  the  infirmity  gradually  diminishes,  the  increased 
sensibility  of  the  auditory  nerve  compensating  for  the  imperfection 
of  the  organic  apparatus."  Dr.  Hennen  cites  a  case  that  he  met 
with,  in  which  the  external  car  was  completely  removed  by  a  cannon- 
shot,  and  yet  the  sense  of  hearing  Avas  as  acute  as  ever.  Wepfer 
relates  a  case  in  which  the  outer  ear  was  destroyed  by  ulceration, 
but  the  hearing  power  was  not  diminished.  Itard  says  :  "  Every- 
thing combines  to  show  that  the  auricle  is  absolutely  useless  in  man  ; 
that  the  hearing  is  not  altered  when  it  is  removed,  I  have  had 
occasion  to  assure  myself  most  positively."  [Traite  des  Maladies 
de  V  Oreille,  t.  I,  1821.)  He  owns,  however,  that  this  opinion  has 
been  opposed  by  various  anatomists,  among  whom  may  be  cited 
Valsalva  and  Haller,  who  state  positively,  that  although  the  loss  of 


44  TIIEDISEASESOFTHEEAR. 

the  outer  ear  does  not  produce  deafness,  it  is  always  accompanied 
by  a  diminution  of  the  hearing  power.  Leschevin  also  states  that 
those  who  have  lost  tlie  external  ear,  or  have  it  naturally  too  flat 
or  ill-shaped,  have  the  hearing  less  acute.  [Cooper  s  Surgical  Diet. 
7th  Ed.  p.  4G9.) 

An  examination  of  the  details  of  the  cases  from  which  deductions 
have  been  drawn  respecting  the  functions  of  the  external  ear,  shows 
that  experiments  sufiiciently  careful  to  decide  the  question  were  not 
performed.  In  those  instances  in  which  a  diminished  power  of 
hearing  was  detected,  the  condition  of  the  other  parts  of  the  organ 
is  not  recorded ;  and  where  the  patients  are  described  as  hearing 
perfectly,  no  accurate  test  of  the  hearing  power  was  employed ;  nor 
does  it  appear  that  sufficient  care  was  taken  to  ascertain  whether 
the  supposed  perfect  hearing  depended  upon  the  organ  that  remained 
unmutilated.  I  am,  therefore,  happy  that  it  is  in  my  power  to 
record  a  case  in  which  these  particulars  were  carefully  noted. 

Case.  The  right  external  car  removed. — W.  B.,  a  sailor,  aged 
33.  The  whole  of  the  upper  portion  of  the  left  auricle  is  absent. 
The  antitragus  remains,  and  also  a  portion  of  the  tragus,  about 
equal  to  it  in  size ;  below  these  the  remnant  of  the  lobe  slopes 
gradually  down  to  the  side  of  the  neck.  He  states  that  his  ear  was 
bitten  off  by  another  sailor  at  one  of  the  Navigator  Islands ;  but 
the  state  of  the  parts  rather  indicates  a  removal  by  a  cutting  instru- 
ment. The  patient  had  come  from  California,  Avhere  the  practice 
existed  of  cuttino;  off  the  right  ear  of  a  thief.  lie  was  anxious  to 
return  to  California,  but  very  unwilling  to  appear  there  without  his 
right  ear,  and  therefore  applied  to  me  to  aid  him  in  obtaining  an 
artificial  substitute.  His  very  long  hair  entirely  concealed  the 
remaining  ear,  and  prevented  any  one  from  detecting  the  absence 
of  the  other.  Long  hair  in  men  was,  however,  in  California  so  sus- 
picious a  feature,  that  wearing  the  hair  short  about  the  cars  was  not 
merely  fashionable,  but  absolutely  essential  to  a  respectable  appear- 
ance. When  examining  the  patient,  I  found  that  each  meatus  con- 
tained cerumen,  after  the  removal  of  which  by  the  syringe,  he  heard 
the  watch  equally  well  with  either  ear,  at  a  distance  of  two  feet : 
nor,  after  careful  experiments,  could  I  detect  any  difference  between 
the  hearing  power  of  the  two  ears.  I  sent  this  patient  to  the  inge- 
nious Mr.  Rein,  from  whom,  I  doubt  not,  lie  obtained  what  he 
required. 

Pathological  Observations. — The  two  classes  of  disease  of  the 


THEEXTERNALEAR.  45 

external  ear  for  which  the  assistance  of  the  surgeon  is  sought,  are, 
first,  malformations,  and,  secondly,  various  kinds  of  inflammation ; 
to  these  may  be  added  cases  of  cysts  and  tumors,  which  are,  how- 
ever, comparatively  rare. 

I.  3IaIformations  of  the  external  ear  generally  coexist  Avith  par- 
tial or  entire  absence  of  the  external  meatus ;  but  as  the  state  of 
the  outer  ear  usually  attracts  attention  first,  I  shall  consider  the 
two  conditions  together  in  this  place.  Sometimes  the  tragus  is 
pressed  backwards  and  inwards  so  as  to  close  the  meatus ;  in  such 
a  case,  the  patient  must  wear  habitually  a  small  silver  tube,  or  have 
a  portion  of  the  tragus  excised.  A  much  more  serious  malformation, 
and  unfortunately  one  that  is  not  uncommon,  consists  in  the  absence 
of  the  cartilage  of  the  external  ear,  together  with  the  external  mea- 
tus ;  the  only  representative  of  these  parts  being  one  or  more  soft 
and  shapeless  duplications  of  the  integuments  :  sometimes,  indeed, 
there  is  no  vestige  of  either  meatus  or  auricle. 

The  attention  of  the  surgeon  is  called  to  cases  of  malformation  of 
the  external  ear,  in  order  that  he  may  give  an  opinion,  in  the  case 
of  infants  newly  born,  as  to  the  amount  of  hearing  they  are  likely 
to  possess ;  or  when  children  with  this  affection  grow  up  with  a 
certain  degree  of  hearing,  to  decide  whether  an  operation  will 
probably  be  of  any  benefit ;  and,  lastly,  to  do  all  in  his  power  to 
diminish  the  deformity  arising  from  the  partial  absence  of  the  ex- 
ternal ear. 

A  case  is  cited  by  Mr.  S.  Cooper  (loc.  cit.  p.  470)  of  a  child  he 
saw,  when  it  was  exhibited  in  London  as  a  curiosity,  which  was 
wholly  destitute  of  external  ears,  and  m.  Avhom  no  meatus  auditorii 
were  visible.  The  child,  nevertheless,  "could  hear  a  great  deal, 
although  the  sense  was  certainly  dull  and  imperfect."  No  careful 
investigation  seems  to  have  been  made  of  this  case,  nor  is  it  stated 
Avhether  the  presence  of  any  meatus  auditorii  could  be  detected 
through  the  integuments.  Judging  from  somewhat  analogous  cases 
which  will  be  cited,  it  is  most  probable  that  the  meatus  was  entirely 
absent. 

Fritclli  and  Ovcrteuffer  are  also  quoted  by  Cooper,  as  having 
seen  cases  in  which  the  outer  ear  was  entirely  absent.  The  former 
says  that  the  physiognomy  of  the  child  resembled  that  of  an  ape, 
and  the  latter  states  that  his  patient  heard  very  well.  In  some  in- 
stances the  auricle  is  deformed  without  any  abnormal  condition  of 
the  meatus  or  tympanum ;  but,  as  a  general  rule,  malformation  of 


46  THEDISEASESOFTUEEAR. 

the  external  ear  is  accompanied  by  a  defective  development  of  the 
meatus  and  tympanic  cavity. 

This  subject  has  been  examined  Avith  care  by  Professor  Allen 
Thomson,  -who  published  a  notice  of  several  cases  of  malformation 
of  the  external  ear,  and  of  ex})eriments  on  the  state  of  hearing  in 
such  persons,  in  the  Edinburgh  Journal  of  Medical  Science,  for 
April,  1847,  to  -wliich  is  appended  an  account  of  the  dissection  of 
a  similar  case  of  malformation  by  myself.  It  appears  that  there 
are  upon  record  only  three  dissections  similar  to  those  now  under 
consideration  :  of  these,  one  is  described  by  Professor  Jaeger  of 
Erlangen,  one  is  in  the  museum  of  the  University  of  Edinburgh, 
and  tlie  third  is  one  made  by  myself,  at  the  request  of  the  Patholo- 
gical Society  of  London,  before  Avhom  it  was  brought  by  Dr.  Lloyd. 
In  the  first  two  instances,  one  ear  only  was  affected.  "  In  both 
(quoting  Dr.  Thomson),  the  labyrinth  appears  to  be  quite  naturally 
formed  ;  the  cavity  of  the  tympanum  and  the  bony  Eustachian  tube 
exist,  but  are  much  smaller  than  usual.  The  chain  of  ossicles  differs 
materially  from  the  natural  structure,  being  united,  in  one  of  the 
examples,  into  one  straight  and  simple  piece,  and,  consequently  as- 
suming very  much  the  form  and  appearance  of  the  columella  of  birds 
or  reptiles.  The  most  striking  departure  from  the  normal  form  of 
the  bone  consists  in  the  entire  obliteration  of  the  meatus  externus, 
wliich  seems  to  be  connected  with  the  absence  of  that  portion  of  the 
temporal  bone  which  forms  the  tj^mpanic  ring  and  lower  side  of  the 
bony  canal  of  the  meatus,  and  the  extension  backwards  of  the  arti- 
cular or  true  glenoid  portion  of  the  temporal  bone  to  twice  its  natu- 
ral breadth.  There  is  a  total  deficiency,  therefore,  of  what  may  be 
termed  the  tympanic  bone,  or  of  that  Avhich  forms  the  posterior  non- 
articular  part  of  the  glenoid  cavity  of  the  temporal  bone,  intervening 
l)etween  the  fissure  of  Glasser  and  tlie  vaginal  ridge  of  the  spinous 
process.  "Were  this  part  of  the  bone  merely  deficient,  the  cavity  of 
the  tympanum  would  be  left  freely  open  below  ;  but  in  the  two  bones 
now  described,  it  seems  to  be  closed  by  the  unusual  extension  of  the 
glenoid  or  articular  portion  of  the  bone  backwards."  In  reviewing 
the  cases  recorded  by  him,  and  comparing  them  with  the  results  of 
dissection,  Dr.  Thomson  arrives  at  the  conclusion  that  the  folloAving 
are  the  most  prominent  points  of  deviation  from  the  natural  form 
and  structure : — 1st.  An  incomplete  development  of  the  integu- 
mental  part  of  the  apparatus,  viz.,  the  external  auricle  and  outer 
part  of  the  meatus.     2d.   The  absence  of  the  membrana  tympani 


THE     EXTERNAL    EA 11.  47 

ring  and  bony  part  of  the  meatus,  in  consequence  of  the  incomplete 
development  of  the  tympanic  bone,  or  a  part  of  the  structure  which, 
in  the  lower  animals,  bears  that  name.  3d.  The  defective  state  of 
the  cavity  of  the  tympanum  and  chain  of  small  bones.  4th.  Occa- 
sional irregularity  or  deficiency  in  the  development  of  the  malar, 
palatal,  and  maxillary  portions  of  the  face."  My  own  dissection 
was  laid  before  the  Pathological  Society  in  1847 ;  both  ears  were 
equally  affected.  The  external  ear  consists  of  a  fold  of  integument 
of  much  the  same  shape  and  size  as  the  natural  lobe,  but  directed 
forwards,  so  that  the  concave  surface  which  usually  looks  outwards 
is  directly  applied  to  the  surface  of  the  head,  and  conceals  the  tra- 


FiG.  2. 


Malformed  right  External  Ear  of  a  chikl. 

gus,  which  is  rather  smaller  than  natural.  There  are  two  orifices 
on  the  upper  part  of  the  interior  surface  of  the  appendage,  and 
one  at  its  posterior  part :  these  are  the  openings  of  mucous  folli- 
cles. The  meatus  externus  is  entirely  absent,  and  a  slight  depres- 
sion in  the  integuments  is  the  only  indication  of  its  usual  position. 
Upon  removal  of  the  integuments,  no  meatus  or  merabrana  tym- 
pani  was  discovered ;  but  in  their  place  is  a  flat  surface  of  bone, 
which  presents  two  fissures,  one  very  narrow,  with  a  direction  for- 
wards, and  a  second,  three  or  four  lines  in  length,  and  from  half  to 
three-quarters  of  a  line  in  breadth,  commencing  at  the  anterior  and 
inferior  part  of  the  other  fissure,  with  a  direction  downwards  and 
slightly  backwards.  This  fissure  is  covered  by  a  membrane.  The 
whole  of  the  tympanic  ring  is  absent,  so  that  the  mastoid  and  squa- 
mous portions  of  the  temporal  bone  are  only  parted  by  these  fissures, 
the  lower  of  which  seems  to  represent  the  Glasserian  fissure  and  the 
external  meatus  united  into  one. 

The  membrane  which  covers  the  fissure  appears  to  be  the  analogue 
of  the  membrana  tympani.     The  zygomatic  process  of  the  temporal 


48 


THE     DISEASES     OF     THE     EAR. 


bone  is  repvescnted  by  a  small  osseous  layer  developed  in  tlie  middle 
of  a  ligament,  ■which  extends  from  the  external  part  of  the  squa- 
mous portion  to  the  orbit :  the  malai:  bone  is  absent,  the  external 


Fig.  3. 


The  rudimentary  Meatus  Auditorium  Externus  of  a  child,  in  the  form  of  a  fissure  pos- 
terior to  the  Condyloid  Process. 


part  of  the  orbital  circle  being  formed  by  a  ligament  connecting  the 
superior  maxillary  and  frontal  bones. 

Upon  removing  the  membrane  just  described,  a  cavity  was  ob- 
served lined  Avith  mucous  membrane  ;  this  is  evidently  the  cavity  of 
the  tympanum,  but  so  very  much  smaller  than  natural,  as  itself  to 
resemble  somewhat  a  fissure  in  the  substance  of  the  bone.  It  mea- 
sures two  lines  in  its  vertical  diameter,  two  and  a  half  from  before 
backwards,  and  about  half  a  line  from  without  inwards.  This  cavity 
contains  two  bones  which  are  the  analogues  of  the  malleus  and  the 
stapes.  The  former  consists  of  a  narrow  process  directed  upwards, 
and  a  globular  body  below,  from  which  another  process  is  directed 
inwards;  but  it  has  no  connection  with  the  stapes  to  which  it  is 
superior.  The  stapes,  instead  of  its  two  crura,  has  a  process  flat- 
tened above  and  below,  and  about  three-fourths  of  a  line  in  length  ; 
to  the  inner  extremity  is  attached  the  base,  firmly  fixed  in  the 
fenestra  ovalis,  while  the  outer  extremity  is  slightly  attenuated  and 
presents  no  articulating  surface.  Over  the  stapes,  and  having  a 
direction  from  above  downwards  and  backwards,  the  portio  dura 
nerve  is  seen  unsurrounded  by  bone,  but  in  contact  with  the  mucous 


THE     EXTERNAL     EAR.  49 

membrane  of  the  tympanum.  The  tensor  tympani  muscle  is  in  a 
natural  state,  as  is  also  the  Eustachian  tube,  which  opens  into  the 
anterior  part  of  the  tympanic  cavity.  The  stapedius  muscle  is  ab- 
sent ;  the  auditory  nerve,  cochlea,  vestibule,  and  semicircular  canals 
appear  in  all  respects  healthy. 

Fig.  4. 


V 


The  Tympanic  Cavity,  with  the  Eustachian  tube,  opening  into  its  anterior  and  inferior  part. 
The  two  ossicles,  detached  from  each  other,  are  to  the  right. 

The  healthy  state  of  the  labyrinth  -would  lead  the  surgeon  to  ex- 
pect that  sufferers  from  this  deformity  might  hear  some  sounds ;  but 
considering  the  absence  of  an  external  meatus  and  membrana  tym- 
pani, and  the  imperfect  state  of  the  tympanic  cavity,  the  compara- 
tively large  amount  of  hearing  enjoyed  must  be  a  source  of  surprise. 
In  the  following  case  there  is  every  reason  to  suppose  that  the  con- 
dition of  the  ears  was  similar  to  that  just  detailed ;  yet  the  power  of 
hearing  was  much  more  acute  than  in  many  instances  in  which  the 
ear  is  perfectl}'-  developed,  but  in  which  there  exists  some  thickening 
of  that  part  of  the  apparatus  essential  to  hearing. 

Case.  Congenital  malformation  of  both  ears,  and  absence  of  the 
meatus  auditorii. — Miss  A.  J.,  aged  22,  consulted  me  in  1851,  on 
the  recommendation  of  Dr.  Thoophilus  Thompson.  On  examina- 
tion, a  very  small  fold  of  integument,  in  which  was  a  delicate  por- 
tion of  cartilage,  represented  each  external  ear.  The  only  vestige 
of  the  meatus  auditorii  was  a  very  slight  depression  on  each  side,  at 
the  floor  of  which  firm  bone  was  felt.  She  heard  tlie  voice  perfectly 
when  spoken  to  loudly  within  a  foot  of  the  head,  and  best  when  the 
voice  was  directed  towards  the  vertex  of  the  head.  She  has  a  slight 
impediment  in  her  speech,  and  her  face  is  short  and  square-shaped  ; 
the  zygomatic  process  appears  to  be  undeveloped.  AVhen  she  at- 
tempts a  forcible  expiration  with  close  nostrils,  she  feels  a  sensation 
of  pressure  in  both  ears.  Does  not  hear  so  well  during  a  cold. 
Three  months  previously  a  surgeon  liad  made  a  crucial  incision  over 

4 


50  THE     DISEASES     OF    THE     EAR. 

the  depression  in  the  left  ear,  but  no  meatus  auditorius  Avas  found. 
The  patient  thought  she  heard  slightly  better  -while  the  surface  was 
kept  open,  but  it  was  found  impossible  to  prevent  it  from  healing. 

Fig.  5. 


RiuHraentary  External  Ear?. 

I  advised  that  no  further  operation  should  be  performed,  and  that 
she  should  rest  content  with  the  amount  of  hearing  she  possessed. 
She  died  about  two  years  afterwards,  but  it  was  found  impracticable 
to  obtain  a  post-mortem  examination. 

In  some  instances  there  has  evidently  been  a  coexistent  abnormal 
development  of  the  labyrinth,  and  the  patients  have  been  wholly 
deaf  from  birth ;  it  is  gratifying,  however,  for  the  surgeon  to  be 
able  to  assure  the  friends  of  infants  respecting  whom  he  may  be  con- 
sulted, that,  as  a  general  ride,  there  is  a  sufficient  development  of 
the  organ  for  educational  purposes  and  the  ordinary  intercourse  of 
life.  Thus  one  of  the  cases  seen  by  Dr.  Allen  Thomson  was  a  boy 
who  went  on  messages  for  his  father,  a  butcher.  lie  could  join  in 
the  conversation  of  those  with  wlioui  he  was  intimate  ;  and  even  a 
stranger  could  communicat*  with  liiiii  liy  employing  slow,  distinct, 
and  rather  loud  articulation.  A  girl  (»f  only  moderate  intelligence, 
partly  from  weakness  and  partly  from  imperfect  hearing,  neverthe- 
less understood  what  was  said  to  her,  if  spoken  slowly  and  distinctly, 
and  always  answered  by  speech.  Attempts  to  improve  the  hearing 
in  similar  cases  by  means  of  operations  have  invariably  been  unsuc- 
cessful ;  first,  because,  as  a  rule,  there  is  an  entire  absence  of  meatus 
and  nu'iid>rana  tyuiiiani ;  and  secondly,  because  it  has  been  found 
impossible  to  keep  the  aperture  in  the  integuments  from  closing.  In 
most  cases  of  deformity  of  the  external  ear  and  meatus,  a  peculiar 
s(|uare  shape  of  the  face  has  been  observed,  the  lower  jaw  being  very 


THE     EXTERNAL     EAR.  51 

short ;  and  there  is  also  not  imfreqiiently  imperfect  speech  and  de- 
glutition. Thus  in  an  infant,  a  month  old,  seen  in  consultation  Avith 
Mr.  Roberts,  of  St.  John's  "Wood,  1853,  the  meatus  auditorii  being 
entirely  absent,  and  the  auricles  only  partially  developed,  the  chin 
receded  much  more  than  natural,  and  there  was  a  not  unfrequent 
regurgitation  through  the  nose  of  the  contents  of  the  stomach  during 
eructation. 

Supernumerary  ears. — Cases  have  been  recorded  in  which  more 
than  two  ears  have  existed.  Mr.  Wilde  says,  that  Cassebohm  relates 
the  case  of  a  child  with  four  ears  ;  two  placed  naturally,  and  two 
lower  down  in  the  neck  :  in  this  instance,  there  were  two  petrous 
portions  to  each  temporal  bone. 

II.  Inflammations  of  the  external  car. 

The  two  kinds  of  inflammation  to  which  the  auricle  is  subject  are 
erysipelas  and  eczema. 

Chronic  Erysipelas. — It  is  unnecessary  here  to  speak  of  the  acute 
form  of  erysipelas,  since  in  its  nature  and  treatment  it  does  not 
differ  from  the  same  disease  attacking  other  parts  of  the  bod3^  The 
chronic  form  of  erysipelas,  however,  deserves  attention  on  account 
of  its  frequency,  the  discomfort  it  produces,  and  its  very  tedious 
character.  It  sometimes  originates  in  the  acute  form  of  the  disease, 
and  often  remains  during  many  years.  By  degrees  the  aviricle  be- 
comes hypertrophied  and  hardened,  the  meatus  not  unfrequently 
closed,  and  the  ear  loses  its  natural  form,  its  surfiice  being  exceed- 
ingly tender.  This  affection  generally  occurs  in  females  beyond  the 
middle  period  of  life. 

Case. — C.  F.,  aged  49,  admitted  under  my  care  at  the  St. 
George's  and  St.  James's  Dispensary,  in  1849.  She  complains  of 
much  tenderness  in  both  external  ears,  which,  on  examination,  are 
observed  to  be  red  and  very  much  thickened  ;  the  integument  and 
subjacent  cellular  tissue  of  the  right  ear  are  hardened,  and  the 
auricle  scarcely  presents  the  general  form  of  the  natural  organ. 

The  patient's  health  was  much  deranged.  A  solution  of  nitrate 
of  silver,  two  grains  to  the  ounce,  was  applied  to  the  ear,  and  mild 
preparations  of  steel  were  administered.  Under  this  treatment  the 
tenderness  of  the  ear  greatly  diminished. 

Chronic  Eczema,  like  chronic  erysipelas,  is  most  frequently  found 
in  females  beyond  forty  years  of  age,  in  whom  there  is  some  consti- 
tutional debility  ;  it  is,  however,  often  met  with  in  children.  It  is 
generally  accompanied  by  extreme  irritation  of  the  auricle,  which  is 


52  THE     DISEASES     OFTHE     EAR. 

of  a  deep-red  color,  and  often  very  smooth  and  shining.  Scales  of 
epidermis  arc  seen  adhering  to  some  of  the  parts,  and  from  others  a 
thin  discharge  exudes.  In  some  cases,  especially  in  adults,  the 
dermis  is  hypertrophied,  and  the  auricle  loses  it  natural  aspect.  If 
necrlected,  it  is  liahle  to  extend  into  the  meatus,  the  dermoid  layer 
of  which  also  becomes  red  and  sensitive,  and  sometimes  tumefied, 
although  not  unfrequently  no  tumefaction  is  apparent ;  the  dermoid 
layer  of  the  meatus  throws  out  a  discharge  very  similar  to  that 
formed  on  the  external  ear  ;  and  sometimes  the  epidermis  collects 
in  quantities  so  large  as  to  obstruct  the  canal,  and  give  rise  to  those 
symptoms  of  pressure  on  the  membrana  tympani  "which  Avill  be  more 
particularly  alluded  to  under  the  diseases  of  the  meatus.  The  treat- 
ment of  chronic  eczema  is  very  similar  to  that  of  chronic  erysipelas. 
Frequent  ablutions  with  tepid  water,  combined  with  emollients,  should 
be  practised  in  the  early  stages  of  the  affection,  when  the  skin  is  very 
sensitive,  and  the  latter  should  be  protected  from  the  air  by  oiled 
silk,  or  very  thin  vulcanized  India-rubber.  Afterwards,  mild  astrin- 
gents are  to  be  used,  and,  as  Mr.  AVildc  recommends,  a  solution  of 
gutta-percha  in  chloroform  may  be  painted  over  the  surface  several 
times  until  a  complete  coat  has  been  formed  ;  which  is  to  be  renewed 
from  day  to  day,  as  often  as  it  peels  off.  The  head  should  be  kept 
cool  ;  and  instead  of  the  ears  being  studiously  covered  by  layers  of 
warm  material,  they  should  be  exposed  as  freely  as  possible,  and 
very  soft  pillows  avoided.  The  meatus  ought  to  be  frequently 
syringed  Avith  tepid  Avater,  for  the  purpose  not  only  of  removing 
the  dead  cuticle  and  discharge,  but  also  of  soothing  the  irritable 
dermoid  membrane.  The  introduction  into  the  meatus  of  ear-picks 
and  other  foreign  bodies,  for  the  purpose  of  allaying  the  itching  of 
tube,  must  be  studiously  avoided  ;  but  if  the  itching  becomes  ver\' 
distressing,  a  vapor-bath  and  hot  injections  should  be  resorted  to. 
In  later  stages  of  the  affection,  when  both  dermis  and  epidermis 
become  thicker  than  natural,  the  ungucntum  zinci  or  the  unguen- 
tum  hydrargyri  nitratis  may  be  employed.  In  addition  to  local 
applications,  constitutional  remedies  should  be  employed.  In  adults 
any  derangement  of  the  general  system  should  be  attended  to,  alter- 
ative medicines  administered,  and  great  attention  to  diet  enjoined, 
as  well  as  abundant  exercise  in  the  open  air.  In  cliildren,  these 
constitutional  remedies  require  to  l)e  still  more  sedulously  used,  and 
where  there  is  a  tendency  to  glandular  enlargement,  sea  or  country 
air  may  be  advantageously  recommended. 


THE     EXTERNAL     EAR.  53 

In  addition  to  the  two  kinds  of  inflammatory  disorder  just 
noticed,  the  auricle  is  sometimes  subject  to  a  chronic  inflammation, 
the  seat  of  which  appears  to  be  the  cartilage  or  its  immediate  invest- 
ment :  it  is  characterized  by  slight  congestion  and  by  extreme  sensi- 
bility upon  pressure.  The  auricle  is  also  often  the  seat  of  chronic 
inflammation  accompanied  by  excoriations  ;  but  frequent  ablution 
Avitli  tepid  water  and  the  use  of  mild  astringents  generally  cflect  a 
cure. 

III.   Ci/sts,  Tumors,  Deposits,  and  Malignant  Diseases. 

Cysts. — The  only  kind  of  cyst  to  which  the  external  ear  is  sub- 
ject, is  that  formed  by  an  efi"usion  of  blood  between  the  cartilage 
and  the  integuments.  It  has  most  generally  been  found  in  insane 
persons ;  and  according  to  ni}^  friend  Dr.  Thurnam,  of  the  Wilts 
County  Asylum,  who  has  paid  particular  attention  to  the  subject, 
and  who  has  favored  me  with  his  experience  upon  it,  it  is  not  now 
so  prevalent  as  formerly.  This  he  ascribes  to  the  fact  that  less 
personal  violence  is  now  used.  It  has  been  thought  by  some  to  be 
peculiar  to  the  insane ;  such,  however,  is  not  the  case,  for  a  patient 
with  this  afiection  was  admitted  under  my  care,  in  the  year  1852,  at 
St.  Mary's  Hospital,  and  one,  if  not  two,  other  cases  of  the  kind 
have  presented  themselves  to  me. 

This  disease,  called  by  Dr.  Stifi",^  Hsematoma  Auris,  is  divided  by 
him  into  four  stages. 

1.  The  stage  of  hyperemia,  and  probably  chronic  inflammation, 
as  shown  by  the  congestion  and  loss  of  the  elasticity  of  the  carti- 
lage. 

2.  The  stage  of  efi'usion ;  an  apoplectic  layer  is  suddenly  formed, 
causing  obliteration  of  the  ridges  and  depressions  of  the  ear. 

3.  The  cystic  stage ;  in  a  comparatively  short  time  absorption 
commences,  the  ridges  reappear,  but  in  altered  shape.  This  stage 
may  last  for  years. 

4.  Permanent  induration,  complete  absorption  of  the  fluid ;  and 
occasionally  atrophy  of  the  ear. 

Dr.  Thurnam  calls  this  disease  "  Hsiematocele  of  the  external  ear." 
In  a  letter  to  me  on  the  subject,  he  says:  "In  the  first  stage  of  this 
affection,  I  believe  an  effusion  of  blood  exists  between  the  folds  of 
the  integuments  and  around  the  fibro-cartilage  of  the  ear  :  if  punc- 
tured in  this  stage,  there  is  a  discharge  of  serum  of  the  blood,  mixed 

'  Medico-Chirurgical  Review,  January,  1858. 


54  THE     DISEASES     OF     THE     EAR. 

with  coagulum.  I  tliink,  liowcver,  the  proper  practice  is,  )iot  to 
puncture  in  this  early  stage,  but  to  apply  evaporating  lotions.  Even 
under  this  treatment,  though  still  more  if  left  to  itself,  the  tumor 


Fig.  6. 


Hematocele  of  the  External  Ear  (AVilde). 

often  increases  so  as  entirely  to  disfigure  the  ear,  and  produces  a 
large  hot  swelling  of  a  livid  red  color.  At  the  end  of  a  week  or 
two,  according  to  circumstances,  I  have  passed,  with  a  common  or 
curved  needle,  a  small  seton  through  the  long  axis,  pressing  out  the 
contents,  Avhich  are  now,  in  addition  to  their  sanguineous  nature, 
more  or  less  purulent,  and  allowing  the  rest  to  escape  gradually.  At 
first  the  diminution  of  the  tumor  is  trifling  ;  but  under  the  use  of 
the  seton  it  gradually  subsides,  and  at  the  end  of  two  or  three  weeks 
a  certain  amount  of  chronic  thickening  only  remains.  Where  no 
such  treatment  has  been  adopted,  the  resulting  deformity  has  been 
very  marked,  and  has  continued  through  life." 

The  patient  who  came  under  my  notice,  at  St.  Marj^'s  Hospital, 
was  a  man  aged  26,  a  boxer,  who  had  received  a  blow  on  the  ear  a 
fortnight  previously.  The  cyst  was  about  the  size  of  a  small  wal- 
nut;  it  had  been  punctured,  and  a  transparent  fluid  was  evacuated; 
it  had,  however,  soon  formed  again.  lie  did  not  return  to  undergo 
any  treatment. 


THE     EXTERNAL     EAR. 


65 


Tumors. — The  lobule  of  the  external  ear  is  subject  to  hyper- 
trophy, and  to  the  development  of  tumors  in  its  substance.  Tumors 
are  also  developed  from  the  surface  of  the  cartilage,  or  from  the 
cellular  tissue  coverino;  it. 


Tumor  of  the  Lobule  (Wilde) . 


Mr.  Wilde  relates  a  case  of  tumor  in  the  substance  of  the  lobule. 
"  M.  S.,  a  female,  aged  19, has  a  hard,  firm,  ovoid  tumor  occup3ang 
the  centre  of  the  lobe  on  each  side,  but  largest  on  the  left.  It  is 
of  a  stony  hardness,  and  is  quite  distinct  both  from  the  cartilage 
above  and  the  fleshy  part  of  the  lobe,  which  it  appears  to  pass 
through.  The  skin  covering  it  is  smooth,  and  of  a  light  pinkish 
hue,  like  that  of  a  keloid  tumor.  It  grew  gradually  from  the  orifice 
made  for  holding  the  ear-ring,  and  has  been  several  months  attaining 
its  present  size.  The  tumor  upon  the  opposite  side,  which  also 
surrounds  the  hole  made  for  the  ear-ring  is  much  paler  in  color, 
and  not  larger  than  a  garden  pea.  The  girl  states  she  expe- 
rienced a  great  deal  of  pain  and  soreness  in  the  wounds  made  in 
piercing  the  ears,  and  that  about  three  or  four  months  afterwards, 
she  was  obliged  to  remove  the  ear-rings,  on  account  of  the  irritation 
they  produced.  The  large  tumor  was  dissected  out,  and  the  ellip- 
tical aperture  left  in  the  lobe  brought  together  with  sutures.  It 
healed  kindly,  and  the  disease  did  not  return.     A  section  of  the 


56  THE    DISEASES     OF    THE    EAR. 

tumor  exhibited  a  dense  yellowish-white  fibrous  appearance,  and  was 
so  hard  that  the  nail  made  no  impression  upon  it." 

Gouty  deposits  are  not  unfrequcnt  in  the  external  ear. 

Scirrhus. — Kramer,  in  his  work  on  the  Diseases  of  the  Ear, 
devotes  a  section  to  the  consideration  of  a  disease  which  he  entitles 
"scirrhous  degeneration  of  the  auricle."  In  its  early  stances,  he 
describes  its  symptoms  as  analogous  to  those  of  erysipelas.  As  the 
disease  advances,  excoriation  and  ulceration  of  the  auricle  takes 
place,  and  the  cartilage  is  perforated  and  destroyed.  The  auricle 
becomes  nodulated  and  misshapen ;  the  nodules  ulcerate.  I  have 
not  met  with  the  disease  unless  when  complicated  with  disease  of 
the  petrous  bone.  Dr.  Kramer  cites  three  cases  of  supposed  scir- 
rhous degeneration :  of  these  the  following  occurred  in  the  practice  of 
Dr.  Fischer  : — A  countryman,  when  eight  years  of  age,  perceived 
an  itching,  which  depended  on  a  scabby  eruption  of  the  head.  This 
extended  to  the  right  ear,  and  its  irritation  being  increased  by 
roughly  rubbing  it  Avith  the  hand,  the  skin  Avas  corroded.  A  redness 
and  swelling  of  the  ear,  the  certain  attendants  of  inflammation, 
continued  from  that  time,  much  encouraged  by  the  plethora  and 
strength  of  the  individual.  The  disease  now  remained  stationary 
for  some  years,  but  at  the  time  of  manhood  it  broke  out  afresh,  and 
with  increased  intensity.  During  his  twentieth  year,  it  had  ac- 
quired so  enormous  an  extent  that  the  whole  auricle  was  converted 
into  a  knotty,  deformed,  and  lumpy  mass,  in  which  the  natural 
projection  could  scarcely  be  detected.  At  the  anterior  and  inferior 
extremity  of  the  antihelix  the  degenerate  mass  had  begun  to  sup- 
purate. Dr.  Fischer  cut  away  with  a  knife  the  whole  degenerated 
ear,  and  the  wound  healed  in  less  than  six  weeks. 


CHAPTER  III. 

THE  EXTERNAL  MEATUS— ITS  EXPLORATION. 

ANATOMICAL     OBSERVATIONS  —  OSSEOUS     MEATUS — MEMBRANOUS     MEATUS OBJECTS     IN 

EXPLORING     THE     MEATUS — MEANS     OP     EXPLORATION — LAMPS — SPECULUJI — MODE     OP 
EXPLORATION. 

The  external  auditory  meatus  is  a  tube  formed  partly  of  cartilage 
and  partly  of  bone.  It  extends  in  a  transverse  direction  from  the 
concha  of  the  outer  ear  to  the  membrana  tympani  internally.  Its 
length  varies  in  the  adult  from  an  inch  and  a  quarter  to  an  inch  and 
a  half. 

The  Osseous  Meatus. — There  is  a  convexity  about  the  middle  of 
the  lower  wall  of  the  osseous  meatus  which  causes  a  slight  central 
contraction  of  the  calibre  of  the  tube  ;  and  this  convexity,  combined 
Avith  a  similar  one  in  the  anterior  wall,  often  prevents  the  anterior 
and  inferior  fourth  or  fifth  of  the  membrana  tympani  being  visible 

Fig.  8. 


A  vertical  section  of  the  left  Meatus  Externus,  from  without  inwards. 

to  the  surgeon  during  his  exploration.  The  superior  and  posterior 
walls  are  slightly  concave  :  the  anterior  Avail  and  floor  of  the  meatus 
extend  three  or  four  lines  further  inwards ;  and  as  the  membrana 


58  TIIEDISEASESOFTHEEAR. 

tjmpani  is  attached  to  the  inner  extremity  of  each  wall,  hence  the 
obli(iuc  position  of  this  membrane.  The  upper  wall  has  intimate 
relations  with  the  cerebral  cavity  ;  the  posterior  is  separated  by  a 
thin  lamina  of  bone  only  from  the  mastoid  cells ;  the  anterior  wall 
forms  part  of  the  glenoid  cavity  and  the  fossa  parotidea.  The  outer 
orifice  of  the  osseous  meatus  is  of  an  oval  shape,  its  longer  axis 
being  from  above  downwards,  and  slightly  backwards.  The  ante- 
rior and  inferior  parts  of  the  orifice  are  rough  and  scabrous,  the 
fibro-cartilage  of  the  meatus  being  firmly  inserted  into  them.  The 
posterior  and  superior  parts  of  the  orifice  are  smooth,  and  perforated 
by  numerous  orifices  for  the  transmission  of  vessels.  The  inner  ori- 
fice of  the  meatus  is  round,  and  in  the  groove  of  its  margin  the  cir- 
cumference of  the  membrana  tympani  is  inserted. 

The  diameter  of  the  external  meatus  varies  much.  In  some  adults, 
it  is  so  large  as  to  admit  the  introduction  into  it  of  the  end  of  the 
little  finger  for  a  considerable  distance,  and  the  membrana  tympani 
may  be  seen  by  means  of  tlie  ordinary  daylight,  without  the  lobe 
being  drawn  back.  In  other  persons,  the  meatus  is  so  small  as 
scarcely  to  admit  a  common  goose-quill.  The  large  size  of  the  meatus 
depends  generally  upon  the  original  conformation  of  the  bony  tube, 
but  its  contracted  state  is  often  the  result  of  osseous  development,  or 
a  thickened  condition  of  the  dermis,  or  the  presence  of  bony  tumors. 

The  membranous  meatus  consists  of  the  following  lamina?,  begin- 
ning internally  : — 1st,  the  epidermis ;  2d,  the  dermis  ;  3d,  the  peri- 
osteum. Between  the  dermis  and  the  periosteum  of  the  outer  portion 
of  the  tube  are  placed  fibro-cartilage,  cellular  tissue,  and  ceruminous 
glands.  The  c])idermis  forms  a  cul-de-sac,  which  covers  the  whole 
of  the  outer  surface  of  the  dermis,  and  is  prolonged  over  the  outer 
surface  of  the  membrana  tympani,  of  Avhich  it  forms  the  outermost 
lamina.  In  the  outer  part  of  the  tube  the  epidermis  is  thick,  and 
is  perforated  by  the  ducts  of  the  ceruminous  glands.  Near  to  the 
outlet,  it  presents  orifices  for  the  passage  of  the  hairs  which  fre- 
quently protect  the  entrance  of  the  meatus.  At  the  inner  half  of 
the  tube,  the  epidermis  is  extremely  thin,  with  a  shining  surface. 
The  scales  which  compose  the  epidermis  are  constantly  throAvn  off 
from  the  free  surface  of  the  membrane :  they  mix  with  the  cerumen, 
and  in  the  healthy  ear  are  excreted  with  it. 

The  dermis  also  forms  a  cul-de-sac  by  being  continuous  with  the 
dermoid  layer  of  the  membrana  tympani.  Near  to  the  orifice  of  the 
meatus,  the  dermis  differs  but  little  from  that  covering  the  cartilage 


THE  EXTERNAL  MEATUS ITS  EXPLORATION.     59 

of  the  concha,  Avith  the  exception  that  it  gives  insertion,  particularly 
in  elderly  persons,  to  numerous  short  strong  hairs.  More  internally, 
the  dermis  is  remarkable  for  its  extreme  sensibility,  and  gives  pas- 
sage to  the  ducts  of  the  ccruminous  glands.  The  outer  half  of  the 
dermis  is  firmly  connected,  anteriorly  and  inferiorly,  to  the  fibro- 
cartilage  ;  posteriorly  and  superiorly,  where  there  is  no  fibro-carti- 
lage ;  the  dermis  is  connected  to  the  superior  and  posterior  parts  of 
the  osseous  meatus  by  loose  cellular  tissue,  in  which  the  ceruminous 
glands  are  placed.  At  the  inner  half  of  the  tube,  the  dermis  is 
intimately  connected  with  the  periosteum,  the  two  membranes  being 
frequently  inseparable. 

The  outer  half  of  the  membranous  meatus  contains,  in  addition  to 
the  laminte  previously  noticed,  fihro-cartilage,  which  is  continuous 
externally  with  that  forming  the  external  ear,  and,  internally,  is 
attached  to  the  rough  margin  of  the  osseous  meatus  by  fibrous  tissue, 
which  admits  of  considerable  motion  taking  place  between  the  car- 
tilage and  the  bone.  The  outer  part  of  the  fibro-cartilage  of  the 
meatus  projects  and  forms  the  tragus.     The  fibro-cartilaginous  meatus 


Fig.  9. 


The  Orifice  of  the  Meatus  Externus,  showing  its  oval  shape. 

does  not  form  a  complete  tube,  being  deficient  at  its  posterior  and  supe- 
rior third,  where  the  bloodvessels  of  the  bone  freely  communicate  with 
those  of  the  meatus.  The  shape  of  the  orifice  of  the  meatus,  consist- 
ing of  fibro-cartilage,  is  more  oval  than  that  of  the  osseous  meatus, 
and  is  composed,  anteriorly  and  inferiorly,  of  the  fibro-cartilage, 
covered  by  the  dermis,  posteriorly  of  the  anterior  border  of  the 


60 


THE     DISEASES     OF    THE     EAR. 


concha,  which  projects  slightly  foi'Avards.  The  superior  part  of  the 
orifice  does  not  contain  any  fibro-cartilage ;  Init  in  the  remaining 
portions,  the  dermis  is  connected  with  the  fibro-cartilage  by  very 
dense  cellular  tissue.  That  the  orifice  of  the  meatus  externus  is 
oval  i.s  shown  by  simply  introducing  the  index  finger  within  it  in  the 
living  subject.  It  will  be  found  that  the  finger  (itself  of  an  oval 
shape)  enters  some  slight  distance,  and  that  its  anterior  and  posterior 
surface  are  in  contact  with  the  corresponding  surfaces  of  the  orifice  ; 
but  if  the  posterior  surface  of  the  finger  be  directed  upwards,  and 
the  anterior  downwards,  its  entrance  is  impossible.  The  orifice  of 
the  external  meatus  is  its  narrowest  part,  and  its  cavity  and  the 
membrana  tympani  are  guarded  by  the  slight  projection  posteriorly 
of  the  tragus,  while  the  posterior  margin  of  the  orifice  projects 
slightly  forwards.  Thus  the  introduction  of  a  foreign  body  is  pre- 
vented by  the  flap  of  the  tragus  covering  the  orifice  ;  and  if  that  be 
pushed  aside  or  penetrated,  then  the  projecting  posterior  border  of 
the  orifice  directs  the  body  against  the  anterior  wall  of  the  meatus. 
This  condition  of  the  orifice  of  the  meatus  is  also  of  great  use  in 
preventing  the  sudden  rush  of  cold  air  to  the  surface  of  the  mem- 
brana tympani,  and  the  passage  of  water  to  it,  when  the  head  is 
immersed,  or  copious  ablutions  are  practised.  The  projection  of  the 
tragus  backwards,  and  of  the  cartilage  forming  the  posterior  margin 
of  the  meatus  forwards,  consequently  gives  a  curved  form  to  the  tube, 
which  curvature  is  increased  by  the  direction  of  the  osseous  tube 
being  first  slightly  forwards,  then  backwards,  and  lastly,  somewhat 
forwards  again. 

Fig.  10. 


The  Osseous  Meatus  Externus  of  an  infant. 


At  birth,  only  the  rudiments  of  the  osseous  external  meatus  are 
present :  these  consist  of  a  delicate  osseous  ring,  which,  however,  is 


THE  EXTERNAL  MEATUS ITS  EXPLORATION.    61 

incomplete  at  tlie  upper  fourtli,  where  the  surface  of  the  temporal 
bone  is  smooth  and  slightly  concave.  The  upper  part  of  the  mem- 
branous meatus  rests  on  this  portion  of  bone.  The  inner  margin  of 
the  remainder  is  attached  to  the  annulus  auditorius  ;  its  outer  sur- 
face is  in  contact  "with  the  adjacent  tissues.  As  the  child  grows, 
the  smooth  superior  surface  is  gradually  developed  into  the  concave 
upper  wall  of  the  meatus,  and  from  the  osseous  ring  spring  the  ante- 
rior, posterior,  and  inferior  walls. 

In  the  exploration  of  the  meatus,  the  object  of  the  surgeon  is 
threefold. 

I.  To  render  the  meatus  as  straight  as  is  practicable. 

II.  To  dilate  slightly  the  outer  membranous  and  cartilaginous 
portion. 

III.  To  throw  as  much  light  as  possible  on  the  walls  of  the  meatus. 

To  straighten  the  meatus  it  is  necessary  to  press  the  tragus  for- 
wards, and  the  cartilage  forming  the  posterior  wall  of  the  meatus 
backwards.  When  the  meatus  is  very  large,  this  may  be  accom- 
plished by  simply  pulling  the  outer  ear  backwards  by  the  finger  and 
thumb,  at  the  same  time  that  the  tragus  is  pressed  forwards  by 
another  finger  ;  but  this  is  better  effected  by  the  aid  of  the  speculum 
auris,  which  at  the  same  time  dilates  the  orifice.  Some  writers  have 
supposed  that  it  is  not  desirable  to  use  any  instrument  for  this  pur- 
pose ;  but  the  orifice  of  the  meatus  is  generally  so  small  that  it  is 
important  to  dilate  it  as  Avidely  as  possible  without  causing  pain,  in 
order  to  allow  the  passage  of  a  sufficient  volume  of  the  rays  of  light 
to  permit  the  inspection  of  the  surface  of  the  meatus,  and  of  that  of 
the  membrana  tympani.  That  the  orifice  of  the  meatus  is  suscep- 
tible of  being  dilated  is  shown  by  placing  the  end  of  a  finger  in  it, 
and  then  pressing  it  gently  inwards,  when  the  walls  will  be  felt  to 
yield  slightly,  and  to  embrace  the  finger  firmly. 

For  the  proper  inspection  of  the  meatus  a  strong  light  is  required, 
which  can  be  so  thrown  as  thoroughly  to  illuminate  the  visible  sur- 
faces of  the  meatus  externus  and  the  membrana  tympani.  Sunlight 
is  the  best ;  but  as  its  presence  in  om"  variable  climate  can  rarely  be 
made  available,  and  as  the  surgeon  must  be  prepared  to  make  his 
observations  at  all  times  of  the  day  and  night,  and  often  on  patients 
lying  in  bed,  it  is  clear  his  usual  resort  must  be  to  artificial  light. 
By  a  careful  use  of  this  light,  however,  he  may,  with  few  exceptions, 
attain  to  such  a  knowledge  of  the  condition  of  the  surfaces  illumi- 
nated as  will  suffice  for  his  guidance. 


62 


THE     DISEASES     OF     THE     EAR. 


There  are  two  lamps  ■\vliicli  throw  a  good  light  into  the  meatus, 
M.  Segalas's  and  Mr.  Miller's. 

iSiyahiif' s  lamp  is  of  very  simple  construction,  but  can  oidy  be 
used  with  gas.     It  consists  of  two  vertical  iron  rods,  the  anterior 


Fig.  11. 


The  mode  of  examining  the  Ear  by  aid  of  sunlight.' 

of  which  is  about  four  inches  high,  and  surmounted  by  a  gas-burner 
whicli  tonniiunicates  with  the  vulcanized  indiarubber  gas-tube.  This 
vertical  rod  is  connected  by  a  horizontal  rod,  four  inches  long,  with 
a  second  vertical  rod  about  three  inches  high,  to  the  summit  of  which 
is  fi.xed  a  circular  reflector  about  four  and  a  half  inches  in  diameter ; 
and  in  the  centre  of  which  is  an  orifice  for  the  surgeon  to  look  tlirough, 
about  half  an  inch  in  diameter.  Attached  to  the  horizontal  rod  is 
a  ball  and  socket-joint,  and  a  handle  and  movable  piece  by  which 
the  lamp  may  be  held  in  the  mouth,  and  thus  l)oth  hands  left  at 
liberty. 

Miller  8  lamj),  called  after  its  manufacturer,  was  first  suggested 
by  Dr.  Chowne ;  "but  it  has  undergone  great  improvements  in  the 
hands  of  its  maker.  It  consists  of  a  wax  candle,  inclosed  in  a 
Palmer's  spring  tube,  about  six  inches  in  length,  standing  upon  a 
foot  aljout  two  and  a  half  inches  in   diameter  and  three-quarters  of 


'  In  this  figure  the  head  of  the  patient  ought  to  incline  more  to  the  right  shoulder. 


THE  EXTERNAL  MEATUS ITS  EXPLORATION. 


63 


an  inch  deep,  so  as  to  hold  the  reflector  when  not  m  use.  For  the 
top  there  is  a  cap  -which  acts  as  an  extinguisher,  and  also  as  a  de- 
fence to  the  candle  when  carried  about.    This  lamp  will,  I  think,  he 


Fig.  12. 


Fig.  13. 


Miller's  Lamp,  open. 


Miller's  Lamp,  closed. 


found  efiicient  and  economical,  not  merely  in  cases  of  disease  of  the 
ear,  but  in  all  cases  where  a  lamp  is  required. 

In  addition  to  the  lamp,  specula  are  necessary  for  the  examination 
of  the  ear. 

Speculum  aicris. — Various  complicated  and  somewhat  expensive 
instruments  have  been  invented  for  the  purpose  of  straightening 
the  outer  half  of  the  meatus,  for  slightly  dilating  it,  and  for  con- 
centrating the  rays  of  the  sun,  or  of  an  artificial  light,  on  the  sur- 
face of  the  tube  and  on  the  membrana  tympani.  The  one  in  general 
use  previous  to  the  last  ten  years  was  the  foi'ceps-specuJum:  it  is 
made  of  steel,  and  consists  of  two  handles  or  branches  crossing  each 
other,  but  having  a  strong  spring  between  them  ;  each  of  these 
branches  is  attached,  at  the  extremity  furthest  from  the  handle,  to 
half  a  metallic  funnel,  and  when  the  handles  are  pressed  together, 
the  two  halves  of  tlie  funnel  separate.  Is  is  used  by  placing  the 
small  extremity  of  the  funnel  in  the  outer  part  of  the  meatus,  and 


64  THE     DISEASES     OFTUE     EAR. 

then  opening  it  so  as  to  dilate  tlie  tube.  The  objections  to  the  for- 
ceps-speculum, and  indeed  to  all  modifications  of  it,  consist  in  its 
being  cumbrous,  expensive,  and  not  efficient.  Thus  this  instrument 
is  too  heavy  to  remain  in  the  external  meatus  without  being  held ; 
on  account  of  its  weight  and  size  it  cannot  be  used  "with  delicacy, 
while  a  sensitive  meatus  is  liable  to  be  pained  by  it ;  further,  it  re- 
quires the  exclusive  use  of  one  hand,  so  that  it  cannot  be  well  em- 
ployed during  the  performance  of  an  operation,  or  the  use  of  ajiplica- 
tions  to  the  meatus  or  mcmbrana  tympani.  Another  great  oly'ection 
to  the  forceps-speculum  is,  that  when  the  tAvo  portions  of  the  funnel 
are  st'()arated  in  the  meatus,  two  spaces  are  left  between  them,  through 
which  hairs  or  portions  of  epidermis  and  cerumen  often  project,  and 
obstruct  the  passage  of  light. 

To  remedy  some  of  the  above  defects,  the  tubular  ear-speculum 
was  invented  by  Dr.  Gruber,  of  Vienna,  and  introduced  to  the  notice 
of  English  surgeons  by  Mr.  Wilde,  in  his  paper  on  Otorrhjea,  pub- 
lished in  1844  in  the  Dublin  Journal  of  3Iedieal  Science.  Mr. 
Wilde  describes  it  as  consisting  of  "  a  small  conical  tube  of  silver, 
measurinff  about  an  inch  and  a  half  in  length,  five-eifjliths  of  an  inch 
in  width  at  the  greater  aperture,  and  varying  from  two  to  four  lines 
in  the  clear  at  the  small  extremity."  The  interior  and  exterior  of 
each  extremity  is  polished,  and  both  openings  are  circular.  Two  or 
three  sizes  are  recommended.  There  can  be  no  doubt  that  this 
speculum  was  a  great  improvement  over  any  previously  suggested  ; 
but  upon  comparing  its  shape  with  that  of  the  tube  it  is  intended  to 
explore,  two  grave  defects  are  detected.  The  first  is  the  coniform 
shape  of  its  small  extremity  ;  for  the  widest  part  of  the  speculum  is 
introduced  into  the  narrowest  part  of  the  tube,  and  its  extremity 
projects  into  and  obstructs  that  portion  of  the  meatus  which  it  is 
desirable  should  be  free.  With  a  speculum  of  this  shape  it  is, 
secondly,  very  difficult  to  explore  the  whole  of  the  meatus,  and  it  is 
not  sufficiently  embraced  by  the  meatus  to  retain  its  position  without 
being  held.  These  disadvantages  of  the  conical  speculum  were  ob- 
served by  the  late  Mr.  Avery,  who  devoted  so  much  time,  and  did 
so  much  to  facilitate  the  exploration  of  the  various  mucous  canals. 
He  suggested  that  the  narrower  portion  of  the  speculum,  for  about 
three-quarters  of  an  inch,  should  be  of  the  same  diameter  throughout. 
There  remained,  however,  tlie  other  very  serious  defect  in  the  tubu- 
lar speculum  of  the  circular  form  of  its  small  extremity.  As  has 
been  said,  the  surgeon  can  readily  assure  himself  of  the  oval  shape 


THE  EXTERNAL  MEATUS ITS  EXPLORATION. 


65 


of  the  outer  meatus,  and  that  the  anterior  and  posterior  walls  of  the 
tube  are  flat  and  only  slightly  concave ;  a  form  that  also  partially 
obtains  in  the  bone.  It  is  clear,  therefore,  that  when  a  circular  tube 
is  introduced  into  this  oval-shaped  meatus,  it  may  press  against  the 
anterior  and  posterior  walls,  and  yet  leave  a  considerable  space  above 
and  below  it  unoccupied.  As  a  rule,  therefore,  it  is  impossible  by 
means  of  this  form  of  instrument  to  obtain  a  view  of  more  than  a 
small  portion  of  the  meatus  arid  membrana  tympani  at  the  same 
time  ;  and  should  the  meatus  be  very  small,  the  circular  tube  does 
not  give  passage  to  a  suflficient  quantity  of  luminous  rays  to  enable 
the  surface  of  the  membrana  tympani  to  be  discerned.  Another 
disadvantage  of  the  circular  speculum  is,  that  the  pressure  of  its 
convex  surface  against  the  anterior  and  posterior  walls  of  the  meatus, 

Fig.  14. 


A  set  of  Specula  for  the  purpose  of  examining  the  External  Meatus 


which  are  nearly  flat,  is  liable  to  produce  pain,  especially  where  the 
tube  is  small.  It  is  therefore  evident  that  the  part  of  the  speculum 
inserted  into  the  meatus  should  be  of  an  oval  shape.  This  modifica- 
tion of  the  tubular  ear-speculum  Avas  suggested  by  me  in  a  paper  in 
the  Lancet,  published  in  August,  1850  ;  since  which  time  most  of 
these  instruments  have,  I  believe,  been  made  of  this  shape,  and  have 
been  found  to  answer  every  purpose  for  which  a  speculum  auris  can 
be  required.  In  order  to  hold  the  speculum  more  firmly,  it  is  desira- 
ble that  the  expanded  portion  should  bo  somewhat  flattened  ;  and  this 
flattening  should  be  at  right  angles  with  that  of  the  smaller  extremity, 
A  set  of  three  or  four  specula  should  be  in  possession  of  the  surgeon. 
It  has  been  suggested  that  the  tubular  ear-speculum  should  be  made 

5 


66 


THE    DISEASES    OF    THE     EAR. 


of  glass  silvered  ;  but  the  thickness  of  the  material  would,  occupy  too 
large  a  portion  of  the  cavity  of  tlie  meatus. 

Mode  of  examination. — After  the  preliminary  investigation  has 
been  conducted,  the  patient  being  as  nearly  as  possible  on  a  level 
with  the  surgeon,  the  latter,  taking  the  lamp  in  one  hand,  sliould 
feel  and  inspect  the  external  ear  and  the  orifice  of  the  meatus,  Avith- 
out  the  use  of  the  speculum.  Having  done  this,  a  speculum  adapted 
to  the  size  of  the  meatus  is  to  be  taken  in  hand,  and  introduced  into 
the  orifice  of  the  meatus,  care  being  taken  that  the  long  diameter  of 
each  coincides.  If  the  speculum  enters  very  easily,  and  there  ap- 
pears to  be  room  for  a  larger  one,  the  next  size  should  be  selected, 
and  the  orifice  fully  dilated ;  for  in  all  cases,  the  larger  the  speculum 
used  the  greater  will  be  the  quantity  of  luminous  rays  entering  the 
tube,  and  the  more  complete  the  view  of  the  meatus  and  membrana 
tympani.  The  speculum,  having  been  introduced,  is  to  be  pressed 
slightly  backwards,  for  the  reasons  I  have  mentioned,  and  then,  by 

Fig.  15. 


The  Surgeon  examining  the  External  Meatuf:  by  means  of  Miller's  Lamp  and  the 
Tubular  Speculum. 


means  of  the  lamp  in  the  other  hand,  the  rays  of  light  are  to  be  di- 
rected successively  on  the  several  walls  of  the  meatus  and  on  the 
membrana  tympani.     The  size  of  the  different  parts  of  tlie  tube,  the 


THE  EXTERNAL  MEATUS ITS  EXPLORATION.     67 

quantity,  color,  and  position  of  the  cerumen,  if  present,  should  be 
noted ;  if  absent,  the  state  of  the  part  of  the  tube  in  which  it  natu- 
rally exists,  and  the  degree  of  vascularity  of  the  dermis  lining  the 
inner  half  of  the  meatus. 

A  considerable  degree  of  care  is  required  in  the  examination  of 
the  meatus  in  the  infant  and  child.  The  total  absence  of  the  osseous 
meatus  in  the  former,  and  its  very  limited  size  in  the  latter,  should 
always  be  borne  in  mind,  or  the  surgeon,  when  he  introduces  the 
speculum,  is  apt  to  press  upon  the  membrana  tympani.  In  many 
cases  it  is  necessary  only  to  open  the  orifice  of  the  meatus,  when  the 
membrana  tympani  is  at  once  seen  Avithout  the  introduction  of  the 
speculum  any  further. 


CHAPTER    IV. 

THE   EXTERNAL  MEATUS  {coniinued). 

OX    FOREIGN   BODIES    AND    ACCUMULATIONS    OF   CERUMEN   IN 
THE    MEATUS. 


FOREIGN    BODIES    IN    THE    MEATUS — MODE  OF  REMOVAL — CASES CERCMINOrS    GLANDS — 

THEIR  DISEASES — ACCCMtJLATIONS  OF  CERUMEN — THEIR  CAUSES — TABLE  OP  TWO 
HUNDRED  CASES  IN  WHICH  THE  CERUMEN  WAS  REMOVED — SYMPTOMS — EFFECTS — 
TREATMENT — MODE    OF    REMOVAL — THE    SYRINGE    AND    ITS    USE — CASES. 


FOREIGN   BODIES    IN   THE    MBATUS. 

Foreign  bodies  are  frequently  introduced  into  the  outer  meatus. 
Among  those  which  have  fallen  under  my  own  notice  may  be  named 
beads,  slate-pencil,  leaves,  a  shell,  a  pea,  sealipg-wax,  a  percussion- 
cap,  a  pin,  a  piece  of  paper,  seeds  of  grass,  tobacco,  wool,  cotton- 
wool, human  hairs,  bacon,  lint,  camel's-hair  pencil,  and  camel's  hair. 
When  a  body  is  put  into  the  meatus  by  design,  it  is  either  done  by 
a  child  in  play,  or  by  an  adult  for  the  purpose  of  medical  treatment, 
or  an  alleviation  of  the  itching  of  the  tube.  "When  a  patient  is  sus- 
pected of  having  a  foreign  body  in  the  ear,  the  first  step  of  the  sur- 
geon is  to  make  a  careful  inspection  of  the  tube  in  suidight  or  with 
the  speculum  and  the  lamp,  with  the  view  of  ascertaining  whether 
there  really  is  anything  present.  In  a  great  number  of  cases,  having 
explored  the  whole  of  the  meatus,  and  seen  the  membrana  tympani, 
he  will  be  able  to  assure  the  patient  or  the  friends  that  no  foreign 
substance  is  there.  For  want  of  this  pre-inspection,  lives  have  been 
destroyed  in  attempting  to  extract  from  the  ear  imaginary  bodies 
which  had  never  lodged  there.  Medical  men  are  not  generally  aware 
of  the  impunity  with  which  a  foreign  substance  may  continue  for  a 
time  in  the  meatus.  It  is  not  uncommon  to  find  a  mass  of  hard 
cerumen  in  contact  with  the  whole  of  the  meatus  and  with  the  outer 


THE     EXTERNAL     MEATUS.  69 

surface  of  the  membrana  tympani,  without  causing  any  pain  or  inflam- 
mation ;  and  I  have  frequently  removed  other  substances,  as  beads, 
pebbles,  &c.,  which  had  been  either  in  contact  with  the  membrana 
tympani  or  in  its  immediate  vicinity,  Avithout  causing  any  painful 
irritation.  Nor  is  this  remarkable  when  it  is  remembered  that  the 
meatus  and  outer  surface  of  the  membrana  tympani  are  a  continua- 
tion of  the  outer  skin,  and,  like  it,  covered  with  a  layer  of  epidermis. 
The  meatus  and  membrana  tympani  are  extremely  sensitive  when 
pressed  upon  by  hard  or  rough  substances ;  but  soft,  smooth  bodies 
may  be  gently  pressed  against  them  without  exciting  pain.  Thus 
the  artificial  membrana  tympani,  made  of  vulcanized  india-rubber, 
is  placed  against  the  outer  surface  of  a  perforated  membrana  tympani 
without  producing  any  unpleasant  sensation. 

When  a  foreign  body  has  been  detected  in  the  external  meatus,  it 
should  be  removed  as  soon  as  possible.  The  syringe  and  warm  water 
are,  as  a  general  rule,  quite  sufficient  to  remove  all  rounded  solid 
bodies.  I  have  succeeded  in  extracting  beads  and  other  hard  sub- 
stances which  appeared  to  be  impacted  in  the  meatus,  by  means  of 
the  syringe  only,  though  a  good  deal  of  time  is  occasionally  required. 
It  may  at  times  be  useful  to  move  the  body  slightly  by  means  of  a 
probe  a  little  bent  downwards,  so  as  to  facilitate  the  passage  of  the 
water  to  the  back  of  it ;  for  the  mode  by  which  the  syringe  acts,  is 
in  forcing  the  warm  water  inwards  behind  the  foreign  body,  and  thus 
gradually  expelling  the  latter  outwards.  Mr.  Wilde  and  other 
writers  recommend  the  use  of  the  curette,  spatula,  or  forceps,  in  the 
extraction  of  extraneous  substances  from  the  meatus  :  but  I  have 
rarely  been  obliged  to  use  any  of  these  instruments,  and  resort  to 
them  should  be  avoided  if  possible.  Dieifenbach,  who  advocated  the 
use  of  a  curved  director,  or  curette,  must  have  met  with  cases  show- 
ing the  practice  to  be  dangerous ;  for  he  says,  "  Should  violent 
bleeding  supervene,  and  there  be  no  likelihood  of  completing  the 
operation  at  one  sitting,  cold  and  afterwards  warm  applications  are 
to  be  resorted  to,  to  prevent  suppuration."  It  is  also  almost  impos- 
sible to  pass  a  curette  between  the  extraneous  substance  and  the 
meatus  without  impelling  that  substance  inwards,  in  which  case  it  is 
very  apt  to  be  pressed /orc?^/?/  against  the  membrana  tympani,  and 
cause  inflammation.  Cases  are  sometimes  met  with  in  which  the 
most  lamentable  results  have  followed  attempts  at  removing  foreign 
bodies  by  instruments.     Death  itself  has  not  unfrequently  happened ; 


70  THE     DISEASES     OF    THE     EAR. 

and  -vvliei-o  tlie  life  of  the  patient  has  been  spared,  the  car  has  some- 
times been  destroyed  and  the  ]>o)'tio  dura  nerve  paralyzed. 

Should  a  patient  apply  for  relief  "who  has  much  inflammation  and 
tumefaction  of  the  meatus,  consequent  perhaps  upon  attempts  pre- 
viously made  to  remove  the  body  by  instruments,  the  best  course  is 
to  apply  leeches  and  fomentations  to  subdue  the  inflammatory 
symptoms,  before  attempting  the  extraction  by  the  syringe. 

In  certain  cases  the  presence  of  a  foreign  body  in  the  meatus 
cives  rise  to  coufrhiu'r,  and  even  to  vomitiiij: ;  svmptoms  ■which  seem 
traceable  to  irritation  of  the  auricular  branch  of  the  pneumo-gastric 
nerve.  A  patient  under  my  care,  "with  a  portion  of  dead  bone  in 
the  meatus,  suffered  under  a  cough,  -which  no  treatment  subdued, 
but  -which  disappeared  as  soon  as  the  bone  -was  removed.  In  a 
notice  of  Professor  Romberg's  work,  in  the  British  and  Foreign 
Medical  Hevieic,  \o\.  XVII,  it  is  stated  tliat  Arnold  met  -with  a 
case  of  chronic  vomiting  in  a  child,  -which  long  resisted  all  medical 
means,  but  -which  -was  cured  by  removing  a  bean  from  each  of  the 
child's  ears. 

There  are  substances  of  a  different  character  from  those  already 
alluded  to  -which  arc  not  so  easily  removable  by  the  syringe.  These 
are  -wool,  cotton--wool,  tobacco,  leaves,  paper,  and  similar  soft  mate- 
rials, -which  expand  in  the  tube  and  perfectly  fill  it.  If  the  syringe 
fails  to  remove  these  bodies,  they  can  be  seized  Avith  the  lever-ring 
forceps,  ^vitll  ^v]lie]l  they  can  be  easily  -witlidra-wn.*  Insects  some- 
times enter  the  meatus,  and  arc  apt  to  cause  more  irritation  than 
the  presence  of  solid  bodies.  If  they  touch  the  membrana  tympani, 
they  cause  extreme  sensitiveness  of  it,  and  spasmodic  contraction  of 
the  tensor  tympani  muscle.  The  use  of  the  syringe,  or,  if  that  be 
not  at  hand,  the  pouring  of  a  little  -warm  -water  into  the  ear,  affords 
instant  relief.  Foreign  bodies  Avhich  press  upon  the  outer  surface 
of  the  membrana  tympani  are  apt  to  force  the  chain  of  bones  inwards, 
and  thus  press  the  stapes  towards  the  vestibule,  causing  the  peculiarly 
distressing  symptoms  of  giddiness  and  confusion  in  the  head  which 
not  unfrequently  attend  upon  an  accumulation  of  cerumen.  These 
cease  as  soon  as  the  foreign  body  is  extracted. 

There  is  little  known  as  to  the  effect  of  narcotics  introduced  into 
the  external  auditory  meatus :  but  I  have  every  reason  to  believe 
that  the  narcotic  property  of  a  piece  of  tobacco  in  the  meatus  was 
the  cause,  in  one  instance,  of  very  serious  cerebral  derangement. 

'  See  a  description  of  this  instrument  in  Chapter  YI. 


I 


THE     EXTERNAL     MEATUS.  71 

It  is  probable  that,  in  the  following  case,  the  foreign  body  escaped 
spontaneously. 

M.  S.,  aged  9,  was  brought  to  me  by  a  medical  man,  in  January, 
1852.  He  stated  that,  on  the  previous  evening,  the  mother  of  the 
child  had  seen  her  put  a  bead  into  the  right  ear ;  that  he  himself 
had  seen  what  he  supposed  to  be  the  bead,  but  he  had  been  unable 
to  extract  it  by  the  forceps.  By  means  of  the  lamp  the  surfaces  of 
the  meatus  and  membrana  tympani  were  seen,  and  the  dermis 
throughout  was  much  congested,  especially  near  the  orifice  where 
the  forceps  had  been  applied,  but  no  foreign  substance  could  be  de- 
tected. 


CASES  OF  FOREIGN  BODIES  REMOVED  FROM  THE  EXTERNAL  MEATUS. 

Case  I.  Slate-pencil  in  the  ear  of  a  cJiild. — J.  S.,  aged  7,  Avas 
brought  to  me  at  the  St.  George's  and  St.  James's  Dispensary,  on 
November  28th,  1849,  her  mother  stating  that  she  had  pushed  a 
piece  of  slate-pencil  into  the  right  ear.  She  had  not  complained  of 
pain,  and  had  slept  well.  Upon  examination,  by  means  of  the 
speculum  and  lamp,  a  rough  piece  of  slate-pencil  was  observed  lying 
on  the  floor  of  the  meatus,  one  end  being  apparently  in  contact  with 
the  membrana  tympani,  while  the  other  looked  towards  the  orifice 
of  the  meatus.  It  was  easily  removed  by  the  syringe  and  warm 
water,  and  found  to  be  nearly  half  an  inch  long,  and  a  quarter  of 
an  inch  broad.  The  membrana  tympani  was  red,  the  bloodvessels 
of  its  dermoid  layer  being  distended.  The  patient  did  not  complain 
of  pain,  and  in  a  few  days  the  membrana  tympani  was  healthy. 

Case  II.  A  percussion-cap  in  the  ear  for  fifteen  years. — C.  E.. 
aged  26,  was  admitted  at  St.  Mary's  Hospital  in  November,  1852. 
She  said  that  lately  she  had  felt  somewhat  deaf  in  both  ears. 
Upon  examination,  a  mass,  like  hardened  wax,  was  observed  near 
the  orifice  of  the  left  meatus.  It  Avas  removed  by  the  syringe,  and 
proved  to  be  a  percussion-cap  surrounded  by  Avax.  The  patient 
said  that  she  remembered,  when  about  11  years  of  age,  she  put  a 
cap  into  her  ear,  but  she  believed  it  had  been  taken  out,  and  had 
never  thought  of  it  since.  The  membrana  tympani  was  concave,  the 
Eustachian  tube  natural,  and  the  power  of  hearing  was  nearly  gone. 
Right  ear :  hearing  distance  seven  inches,  membrana  tympani  dull. 
concave ;  Eustachian  tube  natural.     It  appears  that  the  thickening 


72  THEDISEASESOFTIIEEAR. 

of  the  right  incmbrana  tynipani  had  recently  caused  a  dulness  of 
hearing  in  that  ear  :  the  left  ear  had  doubtless  been  useless  for  some 
time ;  but  so  long  as  the  right  ear  remained  perfect,  the  defect  in 
the  left  was  not  observed. 

Hairs  are  apt  to  collect  in  the  meatus  ;  they  either  enter  in  small 
pieces  while  the  hair  is  being  cut,  or  those  growing  at  the  orifice  fall 
inwards  :  great  iritation  is  caused  by  them. 

Case  III.  A  coUeetion  of  hairs  in  the  external  meatus. — W.  S., 
aged  09,  complained  of  an  extremely  unpleasant  crackling  in  the 
right  ear  whenever  he  moved  the  head  or  ear.  It  came  on  two 
months  before  seeing  me,  after  bathing  in  the  sea;  and  he  had  had 
a  similar  attack  some  years  previously,  which  had  subsided  sponta- 
neously. The  hearing  distance  was  three  inches.  A  large  mass  of 
short  liairs  was  syringed  out  of  the  ear  ;  the  symptom  of  crackling 
at  once  disappeared,  and  the  hearing  distance  became  two  feet. 
Another  gentleman,  from  the  same  cause,  was  troubled  with  excessive 
itching. 

Fig.   16. 


Rectangular  Forceps. 

Case  IV.  A  pin  iiiipaeted  in  the  rneafus. — A.  R.,  a  servant,  aged 
35,  came  in  great  fear  and  in  some  pain,  complaining  that  wliile 
picking  the  left  ear  with  a  pin  she  had  dropped  it  into  the  ear,  and 
was  unable  to  remove  it.  The  head  of  the  pin  was  seen  to  lie  close 
on  the  membrana  tympani  at  its  lower  part,  and  the  point  seemed  to 
be  inserted  in  the  membranous  meatus.  The  syringe  proved  ineffec- 
tual, and  I  therefore  had  to  remove  it  with  the  rectangular  forceps, 
an  instrument  of  great  utility  wliere  the  extraneous  substance  cannot 
be  otherwise  removed.  On  attcni])ting  to  withdraw  the  pin,  I  dis- 
coverctl  that  its  point  was  firmly  fixed  in  tlie  dermis,  and  that  the 
only  way  to  extricate  it  was  to  seize  it  by  the  middle,  jiush  it  gently 


THE     EXTERNAL     MEATUS. 


73 


inwards  against  the  raembrana  tympani,  and  then  suddenly  draw  it 
out. 

Cotton-wooL — In  one  case  a  portion  of  cotton-wool  had  been  in 
the  right  ear  for  ten  years  without  producing  any  other  symptom 
than  a  feeling  of  fulness.  In  the  following  case,  where  it  rested  on 
the  membrana  tympani,  symptoms  similar  to  those  of  pressure  on 
the  brain  were  very  decided. 

Case  V.  Cotton-wool  in  the  meatus. — The  Rev.  0.  M.,  aged  55, 
consulted  me  in  1840.  Since  an  attack  of  measles  when  a  child, 
has  had  a  discharge  from  the  left  ear  ;  and  has  been  accustomed  to 
push  a  portion  of  cotton- wool  into  the  meatus.  Has  lately  suffered 
from  giddiness  and  a  sensation  of  Aveight  on  the  head  ;  which  symp- 
toms his  medical  advisers  thought  were  produced  by  derangement  of 

Fig.  17. 


The  External  Meatus  greatly  dilated  by  a  piece  of  Cotton-wool ;  the  latter  is  seen 
below,  and  to  the  left. 


the  Stomach,  as  during  attacks  of  dyspepsia  he  was  decidedly  worse. 
Upon  examination  a  large  quantity  of  cotton-wool  Avas  observed  in 
the  meatus  in  contact  Avith  the  membrana  tympani  :  it  had  evidently 
been  pushed  in  by  other  portions  which  had  been  thrust  upon  it. 
The  cotton  was  removed  by  means  of  the  syringe,  and  was  found  to 
have  closed  an  orifice  in  the  membrana  tympani.  After  the  removal 
of  the  cotton,  the  attacks  of  giddiness  wholly  subsided. 

In  a  dissection,  of  which  a  drawing  is  subjoined,  I  found  a  piece 
of  cotton-wool  in  the  meatus,  where  it  had  probably  remained  for 
many  years;  and  it  had  so  largely  dilated  the  bony  meatus,  that  the 
index  finger  could  be  passed  in  as  far  as  the  membrana  tympani. 

Case  VI.  A  shell  in  the  meatus  ;  removal  by  instruments  ;  para- 


74  THE     DISEASES     OF    THE     EAR. 

lysis  of  the  jjortio  dura  nerve. — Miss  A.,  aged  14,  consulted  me,  in 
May,  1853,  on  account  of  complete  deafness  of  the  right  ear  and 
paralysis  of  the  right  side  of  tlie  face.  Iler  father  stated  that  eight 
years  previously  she  had,  in  play,  put  a  small  shell  into  the  ear ; 
that  the  surgeon,  in  endeavoring  to  remove  it,  forced  it  deeper  into 
the  ear,  breaking  the  shell,  and  causing  intense  pain.  After  its  re- 
moval there  was  much  discharge  from  the  ear,  and  in  a  few  days  the 
muscles  of  the  right  side  of  the  face  lost  their  power,  Avhich  they 
have  not  regained.  Upon  examination  there  was  no  vestige  of  the 
memhrana  tympani ;  the  mucous  membrane  of  the  tympanum  was 
very  thick  and  red,  and  there  was  not  the  slightest  power  of  hearing. 
Case  VII.  Tobacco  in  the  meatus;  i^ain  and  numbness  in  the 
head;  ^mrtial  stupefaction,  inability  to  walk  straight. — M.  B.  S., 
aged  50,  applied  for  relief  in  1843.  He  stated  that  for  four  months 
he  has  had  pain  and  a  sensation  of  numbness  in  the  right  side  of  the 
head,  which  feelinn;s  are  much  ago-ravated  at  times.  He  also  com- 
plains  of  giddiness,  and  sometimes  reels  across  a  room ;  at  otliers  he 
is  obliged  to  sit  down,  feeling  quite  oppressed  and  stupefied.  He 
has  also  suffered  from  indigestion.  Upon  consulting  a  medical  man, 
he  was  treated  by  cupping,  purgatives,  &c.,  but  without  relief.  Upon 
examination  of  the  right  external  meatus,  a  considerable  quantity 
of  black  matter  was  seen,  which  was  easily  removed,  and  was  found 
to  consist  of  tobacco  in  a  moist  state,  mixed  Avith  cerumen  and  wool. 
The  next  day  the  head-symptoms  were  much  diminished ;  in  a  few 
days  they  wholly  disappeared,  and  the  patient  remained  free  from 
them.  Tiie  tobacco  had  been  introduced  into  the  meatus  a  short 
time  before  the  attack,  on  account  of  toothache.  The  mass  was  soft, 
and  so  loosely  packed  that  it  appears  probable  the  symptoms  were 
caused  by  the  narcotic  principles  of  the  tobacco,  rather  than  by  its 
pressure  on  the  membrana  tympani.  In  cases  of  pressure,  too,  the 
symptoms  disappear  at  once  on  the  removal  of  the  cause ;  whereas, 
in  the  present  instance,  they  subsided  slowly. 


THE    CERUMINOUS    GLANDS    AND    THEIR    DISEASES. 

The  ceruminous  glands  surround  the  outer  half  of  the  membra- 
nous meatus,  Avith  the  exception  of  the  portion  situated  within  a  line 
or  two  of  the  orifice.  They  are  contained  in  the  cellular  tissue  be- 
neath the  dermis,  on  the  surface  of  which  the  ducts  open.     Kolliker 


THE     EXTERNAL    MEATUS.  75 

has  recently  shown  them  to  bo  modifications  of  the  sudoriferous  and 
not  of  the  sebaceous  glands,  as  was  previously  supposed.  The  ceru- 
men secreted  by  these  glands  forms,  in  the  perfectly  healthy  ear,  a 
band  about  half  an  inch  in  length,  and  half  a  line  thick.  This  band 
should  be  of  a  consistence  just  sufficient  to  enable  it  to  retain  its 
position,  at  the  same  time  that  it  can  collect  the  small  particles  of 
dust,  &c.,  which  float  in  the  atmosphere,  and  prevent  their  accumu- 
lation on  the  surface,  or  in  the  vicinity  of  the  membrana  tympani. 
Two  other  functions  ascribed  to  the  cerumen  are,  that  by  its  bitter 
taste  it  prevents  the  ingress  of  insects ;  and  that  in  some  peculiar 
manner  it  assists  the  poAver  of  hearing.  Its  principal  use  is  unques- 
tionably to  arrest  and  collect  the  particles  of  dust.  Its  bitterness 
may  possibly  deter  the  entrance  of  insects  ;  but  the  idea  that  it  me- 
chanically assists  in  collecting  or  conducting  the  sonorous  vibrations 
to  the  labyrinth,  or  that  it  is  of  any  use,  in  fact,  in  the  actual  pro- 
cess of  hearing,  is,  in  my  opinion,  quite  erroneous.  No  doubt  its 
absence  is  very  frequently  accompanied  by  a  diminution  of  the  hear- 
ing power ;  but  this  absence  appears  rather  to  result  from  the  sym- 
pathy which  exists  between  these  glands  and  the  deeper  structures 
of  the  ear.  Very  often,  when  these  return  to  their  normal  state, 
the  ceruminous  glands  again  pour  out  a  healthy  secretion.  The  most 
convincing  proof  that  the  cerumen  does  not  mechanically  assist  in 
the  function  of  hearing  is,  that  in  many  cases,  when  the  ceruminous 
glands  alone  are  affected,  and  their  secretion  consequently  arrested, 
no  diminution  in  the  heai'ing  power  can  be  detected  even  by  the  use 
of  the  most  delicate  tests ;  and  cases  must  frequently  occur  to  medi- 
cal men,  where  there  has  been  a  long-continued  discharge  from  the 
surface  of  the  dermis,  no  cerumen  being  secreted,  without  perceptible 
diminution  of  the  hearing  power.  It  is  also  well  known  that  the 
entire  removal  of  the  ceruminous  secretion  does  not  impair  the  hear- 
ing power  ;  and  in  no  case  of  deafness  has  it  been  shown  that  the 
introduction  of  cerumen  or  of  any  substance  to  supply  its  place,  or 
even  the  promotion  of  its  healthy  secretion  under  the  influence  of 
stimulants,  has  in  the  least  degree  improved  the  hearing.  Indeed, 
if  the  peculiar  properties  of  soft  cerumen  be  considered,  it  must  be 
manifest  that  its  function  would  be  rather  to  absorb  superabundant 
sonorous  undulations  than  to  increase  their  intensity.  The  natural 
method  whereby  the  cerumen  when  it  has  performed  its  duties  is 
expelled  from  the  ear,  is  the  action  upon  the  external  meatus  of  the 
condyloid  process  of  the  lower  jaw,  during  the  movement  of  masti- 


76  THE     DISEASES     OF     THE     EAR. 

cation  .iiul  articulation.  By  these  movements,  the  cerumen  is  brought 
quitf  to  the  orifice  of  the  meatus,  whence  it  either  falls  out  in  small 
particles,  or  is  removed  by  the  towel. 

Diseases  of  the  Cerumhious  Glands. — The  ceruminous  glands 
sometimes  pour  out  a  too  abundant  secretion,  which  is  either  of  a 
light  brown  color  and  softer  than  natural,  or  hard  and  dark  colored  ; 
it  may  also  be  entirely  absent.  When  soft  and  semi-liquid,  it  is 
generally  found  in  young  patients  having  a  tendency  to  glandular 
enlargements,  and  in  whom  the  dermis  of  the  meatus  is  hypertro- 
\)]\\vt\  ;  thus,  without  any  accumulation  beyond  that  which  adheres 
to  tlie  walls  of  the  meatus,  the  cavity  is  nearly  filled  with  cerumen. 
It  is,  however,  generally  found  in  a  state  harder  than  natural  ;  and 
this  condition,  by  preventing  its  free  escape  from  the  ear,  gives  rise 
to  that  very  common  affection,  accumulation  of  cerumen  in  the  ex- 
ternal meatus. 

CoUectiuns  of  Cerumen. — Cerumen  accumulates  in  the  external 
meatus  from  two  different  causes  :  one,  a  primary  affection  of  the 
ceruminous  glands  ;  the  other,  a  secondary  and  sympathetic  derange- 
ment of  the  deeper-seated  cavities.  Thus,  while  in  a  large  number  of 
cases  the  removal  of  the  accumulated  cerumen  is  productive  of  im- 
mediate relief  to  the  deafness  ;  in  others,  the  hearing  is  only  par- 
tially or  not  at  all  benefited  by  the  operation.  In  order  to  ascertain 
the  ninuerical  relation  between  the  cases  of  accumulation  that  are 
cured,  and  those  that  are  only  relieved,  by  the  use  of  the  syringe,  I 
have  arranged  in  a  tabular  form  the  results  of  one  hundred  consecu- 
tive cases  that  have  occurred  in  my  private  practice. 


THE     EXTERNAL     MEATUS. 


77 


TABLE  SHOWING  THE  EFFECT  ON  THE  POWER  OF  HEARING  OF  THE  RE- 
MOVAL OF  AN  ACCUMULATION  OF  CERUMEN  IN  ONE  HUNDRED  CASES  J 
THE    NORMAL   DISTANCE    OF   TESTING-WATCH    BEING    THREE    FEET. 


HEARING    DISTANCE    BEFOllE 

HEARING    DISTANCE    AFTER 

O 

REMOVAL. 

REMOVAL. 

Right  Ear. 

Left  Ear. 

Right  Ear. 

Left  Ear. 

22 

1  inch 

8  inches 

18  inches 

18  inches 

22 

normal :  no  cerumen 

half  an  inch 

normal 

normal 

32 

7  inches 

crack  of  nails 

12  inches 

7  inches 

70 

contact 

contact 

contact 

contact 

33 

half  an  inch 

half  an  inch 

normal 

normal 

35 

2  feet 

half  an  inch 

normal 

normal 

45 

contact 

half  an  inch 

2  inches 

2  inches 

15 

half  an  inch 

3  inches 

normal 

normal 

44 

normal :  no  cerumen 

half  an  inch 

normal 

normal 

59 

1  inch  :   no  cerumen 

crack  of  nails 

1  inch 

crack  of  nails 

25 

crack  of  nails 

3  in. :  no  cerumen 

1  inch 

3  inches 

18 

4  inches 

half  an  inch 

normal 

normal 

29 

5  inches 

normal :  no  cerumen 

normal 

normal 

8 

contact 

contact 

3  inches 

contact 

U 

half  an  inch 

half  an  inch 

half  an  inch 

half  an  inch 

49 

G  inches 

6  inches 

6  inches 

6  inches 

53 

crack  of  nails 

2  in.:  no  cerumen 

4  inches 

2  inches 

28 

half  an  inch 

normal:  no  cerumen 

normal 

normal 

26 

1  inch 

half  an  inch 

8  inches 

7  inches 

26 

half  an  inch 

2  inches 

normal 

12  inches 

49 

9  inches 

1  inch 

9  inches 

1  inch 

19 

7  inches 

1  inch 

7  inches 

24  inches 

32 

quarter  of  an  inch 

half  an  inch 

normal 

normal 

53 

normal 

half  an  inch 

normal 

normal 

30 

half  an  inch 

10  inches 

6  inches 

normal 

— 

2  inches 

I2  inch 

2  inches 

half  an  inch 

41 

18  inches 

5  inches 

18  inches 

8  inches 

65 

contact 

contact 

2  inches 

2  inches 

27 

pressure 

pressure 

half  an  inch 

3  inches 

44 

4  inches 

pressure 

6  inches 

3  inches 

25 

24  inches 

1  inch 

normal 

3  inches 

40 

pressure 

normal 

normal 

normal 

65 

crack  of  nails 

crack  of  nails 

2  inches 

contact 

27 

12  inches 

contact 

normal 

normal 

27 

18  in.:  no  cerumen 

pressure 

18  inches 

18  inches 

70 

pressure 

pressure 

1  inch 

1  inch 

56 

normal 

pressure 

normal 

7  inches 



2  inches 

2  feet 

normal 

normal 

20 

2  inches 

2  in.:  no  cerumen 

2  inches 

2  inches 

53 

24  in.:  no  cerumen 

contact 

24  inches 

12  inches 

38 

contact 

half  an  inch 

normal 

normal 

7 

2  inches 

normal :  no  cerumen 

24  inches 

normal 

14 

2  inches 

5  inches 

24  inches 

24  inches 

29 

2  inches 

6  inches 

normal 

12  inches 

40 

4  inches 

pressure 

8  inches 

5  inches 

14 

contact 

normal:  no  cerumen 

6  inches 

normal 

35 

7  inches 

half  an  inch 

normal 

normal 

22 

2  inches 

contact 

24  inches 

normal 

78 


THE    DISEASES    OF    TUE     EAR. 


BEARING   DISTANCE    BEFORE 

UEARINO    DISTANCE    AFTER 

H 

REMOVAL. 

REMOVAL. 

Rigla  Ear. 

Left  Ear. 

RigJu  ESt. 

Left  Ear. 

45 

IG  inches 

3  inches 

24  inches 

8  inches 

19 

normal :  no  cerumen 

contact 

normal 

normal 

28 

normal :  no  cerumen 

pressure 

normal 

normal 

— 

normal :  no  cerumen 

half  an  inch 

normal 

normal 

46 

quarter  of  an  inch 

pressure 

half  an  inch 

half  an  inch 

23 

4  inches 

5  inches 

normal 

normal 

44 

pressure 

pressure 

normal 

normal 

25 

normal :  no  cerumen 

1  inch 

normal 

normal 

14 

2  inches 

2  inches 

normal 

normal 

60 

1  inch 

1  inch 

9  inches 

9  inches 

27 

normal 

half  an  inch 

normal 

half  an  inch 

50 

18  inches 

pressure 

18  inches 

24  inches 

20 

2  inches 

4  inches 

normal 

normal 

11 

2  inches 

half  an  inch 

8  inches 

8  inches 

50 

2  inches 

normal 

normal 

normal 

45 

half  an  inch 

half  an  inch 

1  inch 

1  inch 

5 

crack  of  nails: 
no  cerumen 

2  inches 

crack  of  nails 

4  inches 

35 

10  inches 

2  inches 

normal 

normal 

28 

1  inch 

24  inches 

24  inches 

24  inches 

41 

normal :  no  cerumen 

contact 

normal 

24  inches 

14 

12  in.:  no  cerumen 

2  inches 

12  inches 

24  inches 

24 

pressure 

pressure 

normal 

2  inches 

60 

1  inch 

contact 

1  inch 

contact 

34 

normal:  no  cerumen 

24  inches 

normal 

normal 

19 

2  inches 

1  inch 

24  inches 

24  inches 

61 

2  inches 

2  inches 

3  inches 

3  inches 

65 

crack  of  nails 

crack  of  nails 

crack  of  nails 

qrack  of  nails 

24 

contact 

2  inches 

normal 

normal 

40 

normal:  no  cerumen 

contact 

normal 

8  inches 

60 

contact 

crack  of  nails 

contact 

crack  of  nails 

56 

quite  deaf:  no  ceru. 

contact 

quite  deaf 

6  inches 

21 

normal :  no  cerumen 

6  inches 

normal 

normal 

40 

6  in.:  no  cerumen 

4  inches 

6  inches 

12  inches 

51 

normal:  no  cerumen 

contact 

normal 

3  inches 

50 

G  inches 

6  inches 

normal 

normal 

55 

crack  of  nails 

contact:  no  cerumen 

contact 

contact 

41 

12  in.:  no  cerumen 

contact 

12  inches 

5  inches 

27 

normal:  no  cerumen 

half  an  inch 

normal 

4  inches 

50 

normal:  no  cerumen 

contact 

normal 

1  inch 

46 

2  inches 

half  an  inch 

24  inches 

G  inches 

35 

normal:  no  cerumen 

pressure 

.normal 

12  inches 

45 

3  inches 

3  inches 

3  inches 

3  inches 

74 

crack  of  nails 

2  inches 

3  inches 

6  inches 

49 

half  an  inch 

half  an  inch 

4  inches 

4  inches 

57 

half  an  inch 

2  inches 

1  inch 

3  inches 

36 

crack  of  nails 

crack  of  nails 

1  inch 

1  inch 

39 

pressure 

crack  of  nails 

normal 

normal 

39 

4  inches 

contact 

normal 

14  inches 

25 

2  inches 

normal :  no  cerumen 

normal 

normal 

52 

8  inches 

1  inch 

8  inches 

2  inches 

54 

normal :  no  cerumen 

contact 

normal 

6  inches 

11 

contact 

contact 

12  inches 

12  inches 

THE     EXTERNAL     MEATUS.  79 

An  analysis  of  the  foregoing  100  cases  shows  the  following  to  be 
the  result  of  the  examination  of  the  200  ears : — 


Ears  restored  to  a  normal  condition,         .......     60 

Ears  in  which  the  hearing  power  was  greatly  improved,  .  .         .         .43 

Ears  in  which  the  hearing  power  was  only  slightly  improved,  .  .  .35 

Ears  in  which  tlie  hearing  power  was  the  same  after  as  before  the  removal 

of  the  cerumen,  ..........     27 

Ears  in  which  there  was  no  wax,  and    in  which   tlie   hearing  power  was 

normal,  the  opposite  ear  being  affected,      ......     24 

Ears  in  which  there  was  no  wax ;  but  in  which  the  hearing  power  was  not 

perfect,  the  opposite  ear  being  affected,     ......     11 

200 


It  thus  appears  that  of  the  165  ears  from  which  cerumen  was  re- 
moved, only  GO  were  cured;  that,  including  the  43  cases  which  were 
much  improved,  there  were  103  cases  of  great  amelioration,  while 
there  were  62  ears  that  were  either  but  slightly  or  not  at  all  im- 
proved. Thus,  out  of  the  165  ears  from  which  a  collection  of  ceru- 
men was  removed,  there  were  105  in  which  there  was  some  other 
disease,  the  restoration  of  the  hearing  not  being  perfect.  The  pre- 
sence of  cerumen  in  the  external  meatus  may  be  symjjtomatic  of 
several  affections,  as  obstruction  of  the  Eustachian  tubes,  or  thick- 
ened condition  of  the  tympanic  mucous  membrane,  debility  of  the 
auditory  nerve,  anchylosis  of  the  stapes,  &c.  ;  it  is  therefore  impor- 
tant that  every  case  should  be  carefully  examined  after  a  collection 
of  this  kind  has  been  removed ;  because,  if  the  hearing  power  be 
not  wholly  restored,  some  other  disease  is  present  which  requires  at- 
tention. 

The  causes  producing  accumulation  of  cerumen  in  cases  not  com- 
plicated with  other  diseases,  are, — a  narrow  calibre  of  the  meatus  ; 
the  application  of  cold  ;  the  admixture  of  dust  with  the  cerumen ; 
and,  not  unfrequently,  the  practice  of  pushing  into  the  ear  the  point 
of  a  towel,  whereby  the  cerumen  is  pressed  into  a  mass  toAvards  the 
membrana  tympani. 

The  symptoms  of  an  accumulation  of  cerumen  are  :  sudden  deaf- 
ness, often  following  a  cold  by  which  the  dermis  is  tumefied ;  bath- 
ing or  the  introduction  of  water  into  the  ear.  This  deafness  is 
often  better  in  the  morning  ;  is  increased  by  the  movements  of  the 
jaw  during  mastication  ;  and  often  disappears  as  suddenly  as  it 
came,  with  a  cracking  sound  in  the  ear.  The  cause  of  the  sudden 
appearance  and  disappearance  of  the  deafness  is  the  movement  of 


80  THEDISEASESOFTHEEAR. 

the  mass  of  cerumen :  when  it  is  so  pUiccd  as  to  allow  sonorous  vi- 
brations to  pass  between  it  and  the  wall  of  the  meatus,  the  hearing 
returns  ;  but  when  it  again  conies  in  contact  with  the  meatus,  the 
deafness  recurs.  Oftentimes  a  feeling  of  fulness  in  the  ear  is  com- 
plained of;  not  unfrequently  there  is  singing  and  giddiness,  and 
sometimes  considerable  pain. 

The  symptoms  of  a  collection  of  cerumen  in  the  meatus  vary 
according  to  the  nature  and  position  of  the  mass.  Sometimes  the 
whole  of  the  meatus  is  distended  by  cerumen,  the  inner  end  of  which 
lies  in  contact  with  the  outer  surface  of  the  membrana  tympani,  of 
which  it  often  forms  a  cast.  In  these  cases,  there  is  often  giddiness 
arising  from  the  pressure  on  the  chain  of  ossicles.  The  symptoms 
of  pressure  on  the  brain  are  familiar  to  most  surgeons ;  but  it  is  not 

Fig.  18. 


Cerumen  in  contact  with  the  outer  surface  of  the  Membranii  Tympani. 

generally  known  that  pressure  on  the  contents  of  the  labyrinth  pro- 
duces somewhat  analogous  symptoms.  A  mass  of  cerumen  may 
force  inwards  the  membrana  tympani  and  the  chain  of  bones,  until 
the  base  of  the  stapes  is  pressed  against  the  contents  of  the  vestibule. 
In  some  cases  of  this  nature,  constant  attacks  of  giddiness  occur  ;  in 
others,  there  is  a  confusion  of  ideas  and  an  inability  to  walk 
straight ;  and  in  a  third  class,  there  is  a  feeling  of  weight  and  pres- 
sure on  the  head.  These  symptoms  are  often  combatted  by  the  use 
of  counter-irritants  antl  depletion  ;  but  the  only  proper  remedy  for 
them  is  the  removal  of  the  accumulation. 

In  certain  cases  there  is  a  large  mass  in  the  outer  half  or  two- 
thirds  of  the  tubes,  while  the  portion  near  the  membrana  tympani 
is  empty ;  in  others  there  is  only  a  small  quantity,  which  adheres 
to  the  outer  surface  of  the  membrana,  and  gives  rise  to  great  irri- 


THE     EXTERNAL     MEATUS. 


81 


tation,  and  irregular  action  of  the  tensor  tympani  muscle.  When 
the  mass  is  very  hard,  it  is  liable  to  cause  inflammation  of  the  der- 
moid meatus.  A  collection  of  cerumen  may  remain  in  the  ear  for 
many  years,  and  the  ears  of  the  patient  may  have  been  frequently 
syringed  without  the  nature  of  the  affection  being  detected.  Those 
accustomed  to  pay  attention  to  cases  of  deafness  will,  however, 
generally  be  able  to  state  when  cerumen  is  present,  even  without 
any  examination.      I  have  frequently  diagnosed  the  disease  from 

Fic.  19. 


Meatus  greatly  dilated  by  cerumen. 

the  written  account  of  a  medical  man ;  and  a  repetition  of  the 
syringing  (which  had  previously  been  practised),  but  with  increased 
vigor,  has  entirely  removed  the  deafness.      An  examination  with 

Fig.  20. 


Anterior  wall  of  the  Osseous  Meatus  partly  absorbed,  following  the  pressure  of 
an  accumulation  of  cerumen. 


the  speculum  and  a  strong  light  should,  however,  always  be  made 
before  adopting  any  treatment. 

The  prolonged  presence  of  hardened   cerumen   in  the  external 

6 


»2  THE     DISEASES     OF     THE     EAR. 

meatus  is  sometimes  productive  of  injury  to  the  walls  of  the  meatus 
and  to  the  memhrana  tympani.  In  my  museum  are  several  speci- 
mens in  which  the  osseous  meatus  has  been  much  dilated ;  others  in 
which  the  bone  has  been  absorbed  in  parts ;  and  in  one  instance  a 
portion  of  wax  was  imbedded  in  the  mastoid  cells,  having  passed 
through  an  orifice  in  the  attenuated  posterior  wall  of  tlie  meatus. 
In  another  instance,  wliere  the  cerumen,  by  its  pressure,  had  caused 
an  ulcerated  orifice  in  the  membrana  tympani,  a  portion  of  it  had 
found  its  way  into  the  cavity  of  the  tympanum. 


Fig.  21. 


Cerumen  projecting  through  the  Membrana   i  _     _         mto  the  Tympanic  Cavity. 

The  treatment  of  cases  in  which  there  is  an  accumulation  of  ceru- 
men of  course  consists  in  its  removal.  The  best,  and  indeed  the 
only  judicious  mode  of  effecting  this,  is  by  the  use  of  the  syringe, 
which  will  thoroughly  clear  out  even  the  hardest  masses.  The  use 
of  other  instruments,  as  the  scoop,  has  been  suggested ;  but  I  have 
rarely  known  them  to  have  been  used  without  the  production  of  pain, 
inflammation,  and  often  of  discharge  from  the  dermis.  No  doubt 
the  ordinary  small  syringe  is  not  powerful  enough  to  remove  a  hard- 
ened mass ;  but  the  one  I  usually  employ,  and  which  is  valuable  for 
many  other  purposes,  holds  three  ounces  and  a  half,  and  is  furnished 
with  two  rings,  so  that  it  can  be  held  in  the  right  hand,  and  leave 
the  left  at  liberty  to  hold  the  ear  of  the  patient. 

The  nozzle  of  the  syringe  consists  of  a  metallic  tube  of  very  small 
size,  wliich  sliould  Ite  made  to  takeoff  until  the  water  has  been  drawn 
in  through  the  large  aperture,  and  tlien  be  again  fi.xed  on.  By  doing 
this,  air  is  kept  out  of  the  syringe  and  much  time  is  saved,  as  it  is 
not  easy  to  fill  a  large-sized  syringe  through  a  small  aj)erture. 
The  point  of  the  nozzle  should  be  somewhat  larger  tlian  the  body  of 


THE     EXTERNAL     MEATUS. 


83 


an  ordinary  probe,  so  that  the  water  may  be  injected  Avitli  sufficient 
force,  and  its  return  at  the  orifice  be  unimpeded.  The  ear  of  the 
patient  should  be  brought  opposite  to  a  window,  and  tlie  point  of  the 


Fig.  22. 


Syringe  and  Nozzle. 

syringe  should  be  placed  at  th^  posterior  part  of  the  orifice  of  the 
meatus,  or  the  stream  is  liable  to  strike  against  the  anterior  wall  of 
the  tube.  Whenever  the  syringe  is  used,  the  ear  should  be  drawn 
backwards  so  as  to  straighten  the  tube  ;  and  if  this  cannot  be  ef- 
fected, on  account  of  the  left  hand  of  the  surgeon  being  otherwise 
engaged,  the  posterior  wall  of  the  meatus  may  be  pressed  back- 
wards by  the  point  of  the  syringe.  Warm  water  alone  is  generally 
sufiicient,  without  the  use  of  any  solvent.  It  should  be  quite  clear ; 
and  it  is  always  desirable  to  have  two  vessels  ;  one  for  the  water 
before  it  is  used,  and  the  other  to  receive  it  when  returning  from 
the  ear.  If  a  glass  vessel  be  used  for  the  latter  purpose,  the  condi- 
tion of  the  water,  and  consequently  of  the  ear,  is  more  readily  as- 
certained. The  use  of  an  ear-spout  is  very  serviceable  during  the 
process  of  syringing.     It  consists  of  a  spring  to  pass  over  the  head, 


84  THE     DISEASES     OF     THE     EAR. 

at  one  end  of  which  is  a  funnel  to  fit  uiKlcr  the  ear,  down  which  the 
water  can  run  into  the  basin. 

In  many  cases,  when  the  collection  of  wax  is  not  very  hard,  the 

Fig.  23. 


Ear-spout,  fitted  on  the  lieml. 

injection  of  one  or  two  syringes  full  of  warm  water  is  sufficient  to 
dislodge  the  mass  ;  in  others,  a  much  longer  time  is  required,  and 
when  the  wax  has  been  very  hard,  I  have  sometimes  injected  warm 
water  for  twenty  minutes  or  half  an  hour  Avithout  removing  any 
particles,  or  even  causing  the  water  to  be  clouded.  At  times,  it  is 
well  to  let  the  wax  become  softened  by  the  water  before  using  the 
syringe  again  ;  and  where  the  cerumen  is  unusually  hard,  or  the 
meatus  so  tender  that  the  syringing  causes  much  pain,  it  is  desirable 
to  order  a  weak  alkaline  solution  to  be  dropped  into  the  ear  in  the 
intervals.  As  it  is  not  desirable  to  proceed  with  the  syringe  when 
there  is  no  wax  left,  the  meatus  should  be  frequently  inspected  to 
ascertain  the  progress  made,  as  the  deposit  frequently  comes  away 
slowly  in  small  pieces  ;  the  last  portion,  however,  is  usually  large, 
and  is  often  a  cast  of  the  membrana  tympani.  After  the  extraction 
of  the  cerumen,  a  piece  of  cotton-wool  may  be  worn  for  a  day  or 
two. 


CASES  OF   ACCUMULATION    OF    CERUMEN   IN   THE   MEATUS    EXTERNUS. 

Case  I. — Mrs,  R.,  aged  38,  consulted  me  in  July,  18r)4,  on  account 
of  great  dulness  of  hearing.     She  stated  tliat.  without  any  previous 


THE     EXTERNAL     MEATUS.  85 

symptoms,  ten  months  previously  she  had  become  suddenly  deaf, 
first  in  one  ear  and  then  in  the  other.  After  being  deaf  for  a  month, 
there  was  a  crack  in  each  ear,  and  she  regained  her  hearing,  which 
had  remained  perfect  until  Avithin  a  few  days,  when,  during  a  severe 
cold,  slie  again  became  deaf.  Upon  examination,  I  found  the  meatus 
of  each  ear  full  of  dark  cerumen  ;  the  hearing  distance  Avas  only  half 
an  inch,  and  the  patient  required  to  be  spoken  to  loudly  within  a 
yard.  Upon  removing  the  cerumen  the  hearing  was  perfectly  re- 
stored. 

Case  II.  3Iass  of  cerumen  extremely  hard  and  very  difficult  to 
remove. — Lord  D.,  aged  between  50  and  60,  consulted  me,  in  April, 
1851,  on  account  of  deafness  in  the  right  ear,  accompanied  by  a 
sensation  of  fulness  in  that  organ.  A  large  mass  of  cerumen  Avas 
detected  in  the  meatus,  Avhich  Avas  not  at  all  affected  by  syringing 
for  half  an  hour.  A  solution  of  carbonate  of  soda  in  Avater  (5j  @  Sj) 
Avas  ordered  to  be  dropped  into  the  ear  for  some  days ;  but  the  mass 
was  scarcely  at  all  softened.  The  application  of  the  solution  Avas 
therefore  continued,  and  it  Avas  only  after  several  Aveeks  that  the 
cerumen  was  dissoh'ed  sufiiciently  to  be  remoA^ed  Avith  ease. 

Case  III.  Accumulation  of  cerumen  attetided  witJi  pain  and  in- 
flammation of  the  dermis. — Miss  H.,  aged  30,  consulted  me  in  May, 
1853,  on  account  of  a  shooting  pain  in  the  right  ear  which  she  had 
experienced,  Avith  scarcely  any  intermission,  during  a  fortnight. 
She  was  not  aAvare  that  the  hearing  poAver  Avas  at  all  diminished. 
On  examination,  each  meatus  Avas  found  full  of  cerumen,  the  hear- 
ing distance  of  the  right  ear  being  half  an  inch  ;  that  of  the  left, 
ten  inches.  The  cerumen  Avas  removed  from  each  ear  ;  and  that  in 
the  right  was  exceedingly  hard,  requiring  frequent  syringing.  The 
hearing  distance  of  the  right  ear  rose  to  six  inches  ;  that  of  the  left 
became  natural.  The  surface  of  the  right  meatus  Avas  red,  and  it 
Avas  SAVollen.  The  pain  ceased,  and  the  symptoms  of  inflammation 
disappeared,  after  the  cerumen  Avas  removed. 

Case  IV.  A  mass  of  cei'umeii  producing  inflammation  of  the  der- 
moid layer  of  the  membrana  tympani. — J.  R.  M.,  aged  55,  a  surgeon, 
complained,  in  1849,  of  pain  in  the  right  ear,  Avith  much  deafness. 
The  pain  Avas  paroxysmal  ;  A^ery  acute ;  and  Avas  increased  during 
the  act  of  SAvallowing.  The  meatus  Avas  found  distended  Avith 
cerumen,  the  removal  of  Avhich  gave  immediate  relief  to  both  pain 
and  deafness.     The  upper  half  of  the  dermoid  layer  of  the  mem- 


86  THE     DISEASES     OF    THE    EAR. 

bnuia  tynipaiii,  against  whicli  the  mass  of  cerumen  had  evidently 
pressed,  was  red  and  much  swollen  ;  the  lower  half  Avas  healthy. 

Case  V.  An  accumulation  of  cerumen  causing  neuralgic  pains  in 
the  face. — G.  W.  II.,  Esq.,  applied  to  me,  in  May,  1853,  on  account 
of  a  dulness  of  hearing  in  the  right  ear,  accompanied  by  slight  pain 
in  the  ear,  and  a  good  deal  of  pain  over  the  right  side  of  the  face. 
This  fiicial  pain  came  on  at  times  very  suddenly,  was  very  acute, 
and  then  disappeared  :  it  had  lasted  for  eight  or  nine  days.  A 
larfje  accumulation  of  cerumen  was  found  to  fill  the  right  ear  :  and 
when  removed  by  the  syringe,  the  dulness  of  hearing,  the  pain  in 
the  car  and  in  the  face,  entirely  disappeared. 

Case  VI.  An  accumulation  of  cerumen  causing  2)itlsation  in  the 
ear. — W.  E.,  Esq.,  aged  53,  consulted  me,  in  October,  1851,  on  ac- 
count of  a  pulsation  in  the  right  ear  whenever  he  reclines,  but  which 
ceases  directly  he  assumes  an  upright  position.  He  also  complained 
of  occasional  singing  in  both  ears.  For  these  symptoms  he  had  for 
some  time  been  under  medical  treatment,  but  it  had  not  succeeded 
in  diminishing  them.  A  mass  of  cerumen  was  found  filling  each 
ear,  the  removal  of  which  improved  the  hearing  greatly,  and  en- 
tirely removed  the  pulsation. 

Case  VII.  A  collection  of  cerumen  in  the  external  meatus  ;  giddi- 
ness and  other  sgmiytoms  of  cerebral  irritation  cured  at  once  by  the 
use  of  the  syringe. — L.  S.  M.,  Esq.,  aged  43,  consulted  me  in  No- 
vember, 1845.  He  stated  that,  five  or  six  years  previously,  he  had 
an  attack  of  deafness  in  the  left  ear,  attended  with  a  considerable 
amount  of  singing  noise ;  since  that  time  he  has  occasionally  felt 
deaf  in  the  morning,  but  has  usually  recovered  his  hearing  during  the 
day,  and  at  times,  after  blowing  his  nose,  he  has  been  deaf  for  a 
short  time.  Eleven  months  ago,  after  going  into  the  open  air  from  a 
warm  room,  a  singing  suddenly  came  on  in  the  right  ear,  and  has 
remained  ever  since.  Latel}'  he  has  had  a  sensation  of  weight  at 
the  top  of  the  head,  and  fre(|uc'nt  attacks  of  giddiness,  which  have 
caused  him  great  alarm.  AVhilc  walking  in  the  street,  he  has  ob- 
served himself  noAv  and  then  to  make  "a  lurch."  Upon  inspecting 
the  ears,  each  meatus  was  found  to  be  nearly  full  of  hardened  ceru- 
men ;  which  was  carefully  removed  by  means  of  the  syringe.  The 
symptoms  immediately  disappeared,  and  he  had  no  recurrence  of 
them.  Another  patient,  an  artist,  who  suffered  in  the  same  way, 
was  so  giddy  that  he  was  obliged  to  lean  on  the  railings,  and  rest, 
on  his  way  to  my  house.    He  was  also  unable  to  discern  the  features 


THE     EXTERNAL     MEATUS.  87 

of  his  "sitter"  for  more  than  a  minute  at  a  time,  and  had  the 
greatest  difficulty  in  writing  an  ordinary  note.  He  likewise  was 
cured  at  once  by  the  removal  of  cerumen  from  each  ear.  A  third 
patient  was  by  the  same  means  cured  of  a  constant  pain  and  numb- 
ness in  the  head  :  in  a  fourth,  the  pain  had  extended  down  the  back. 
The  following;  case  is  also  interestino- : 

Case  VIII.  GonfiLsion  in  the  head,  inahility  to  walk  straight, 
caused  hy  a  collection  of  cerumen. — Mrs.  R.,  aged  45,  consulted  me 
in  April,  1845.  She  stated  that,  four  months  previously,  she  first 
began  to  experience  noises  in  the  ears,  which  were  followed  by  a 
great  amount  of  deafness.  These  symptoms  lasted  seven  weeks, 
and  then  disappeared  for  three  weeks,  at  the  expiration  of  which 
time  they  came  on  again,  accompanied  by  a  sense  of  confusion  in 
the  head.  This,  at  times,  was  so  bad,  that  not  unfrequently,  for  a 
few  seconds,  she  could  not  tell  Avhere  she  was.  She  has  at  times 
been  so  giddy,  that  she  has  reeled  and  fallen  in  the  streets  ;  and,  at 
other  times,  she  has  not  been  able  to  retain  her  hold  of  things,  so 
that  they  have  fallen  from  her  hands.  On  examination,  a  large 
compact  mass  of  cerumen  was  found  in  each  ear  ;  which,  after  some 
syringing,  was  got  rid  of ;  and  the  operation  was  followed  by  the 
entire  disappearance  of  all  the  symptoms. 

In  some  cases,  the  hard  mass  of  cerumen  has  pressed  against  the 
outer  surface  of  the  membrana  tympani,  with  sufficient  force  to  cause 
inflammation  of  its  substance,  and  of  the  mucous  membrane  of  the 
tympanum.  When  this  has  been  the  case,  the  application  of  leeches 
has  been  required  before  the  head-symptoms  entirely  disappeared : 
in  other  instances,  they  have  only  gradually  subsided,  though,  as  a 
general  rule,  they  disappear  with  the  removal  of  the  cerumen. 


CHAPTER    V. 

THE   EXTERNAL  MEATUS   {con(inued). 
THE  DERMIS  AND  ITS  DISEASES. 

1.  ACUTE  INFLAUMATION  : — a,   ACUTE  INFLAMMATION  CONFIXED  TO  THE  DERMIS TREAT- 

MENT— CASES,  b,     ACUTE  INFLAMMATION  EXTENDING  TO  THE   BRAIN  AND  ITS 
MEMBRANES — TREATMENT — CASES. 

2.  CHRONIC   INFLAMMATION  : — a,     CHRONIC   INFLAMMATION,  WITH  UVPEUTROruV  AND 

ACCUMULATION  OF  EPIDERMIS TREATMENT CASES.  I),      CHRONIC   CATARRHAL 

INFLAMMATION — TREATMENT — CASES.   C,   CHRONIC  CATARRHAL  INFLAMMATION  EX- 
TENDING TO  THE  BONE  AND  TO  THE  BRAIN — TREATMENT — CASES.  d,   ULCERATION. 

The  diseases  to  whicli  the  dermis  of  the  external  meatus  is 
subject  are  : — 

I.  Acute  Inflammation,  ending  in  resolution,  discharge  of  scrum, 
mucus  or  pus,  or  in  ulceration. 

II.  Chronic  Inflammation,  Avith  or  -without  discharge,  polypoid 
growths,  or  caries  of  the  bone. 

I.  Acute  Inflammation  of  the  Dermis. 

This  is  one  of  the  diseases  hitherto  comprised  under  the  term 
otitis.  The  external  meatus  is  very  sensitive,  especially  towards 
the  middle.  This  sensibility  is  due  to  the  dermis,  which  is  abun- 
dantly supplied  with  nerves  and  bloodvessels,  and  is  covered  by  a 
delicate  layer  of  epidermis.  This  membrane  is  liable  to  inflammation 
from  many  causes,  such  as  the  introduction  of  foreign  bodies  or 
acrid  drops  into  the  meatus ;  an  accumulation  of  cerumen ;  the 
application  of  cold  or  of  heat,  especially  when  arising  from  sudden 
changes  of  temperature  in  the  weather ;  or  any  debilitating  illness. 

The  sijmptomH  of  this  affection,  at  its  connnencement,  are  a  feel- 
ing of  fulness,  stiffness,  and  uneasiness  in  the  meatus,  which  is  in- 


THE     EXTERNAL     MEATUS.  89 

creased  wlien  the  ear  is  pressed  upon,  or  Avlicn  the  outer  ear  is  moved 
by  its  muscles.  This  sensation  is  followed  by  pain,  often  very  acute, 
although  not  so  distressing  as  in  severe  inflammation  of  the  mucous 
membrane  of  the  tympanum  :  throbbing  and  singing  often  accom- 
pany the  pain,  and  there  is  sometimes  a  diminution  of  the  power  of 
hearing.  The  latter  symptoms  arc  probably  due  to  congestion  of 
the  middle  and  internal  cars.  With  these  symptoms  there  is  gene- 
rally a  quick  pulse,  feverishness,  and  restlessness ;  and  the  pain 
sometimes  extends  over  the  side  of  the  head.  On  examination  in 
the  early  stages,  the  dermoid  meatus  is  seen  to  be  red,  its  blood- 
vessels being  apparent  through  the  epidermis.  This  redness  some- 
times extends  to  the  dermoid  layer  of  the  membrana  tympani,  the 
vessels  in  the  circumference  of  which  become  enlarged.  Should  the 
affection  advance,  the  dermis  becomes  tumefied,  so  as  to  diminish 
the  calibre  of  the  meatus  one-third  or  one-half,  and  the  pain  increases. 
In  some  cases,  these  symptoms  subside  without  the  formation  of 
matter ;  in  others,  a  copious  secretion  suddenly  takes  place,  and  is 
followed  by  such  immediate  relief  that  the  patient  thinks  an  abscess 
has  burst.  Examination,  however,  reveals  the  real  condition  of  the 
meatus.  The  discharge  filling  the  meatus  having  been  carefully 
removed  by  the  syringe,  the  surface  of  the  tumefied  meatus  is  seen 
to  be  of  a  deep  red  color,  wholly  denuded  of  epidermis,  and  in  its 
place  secreting  a  mucous  fluid.  In  the  severe  forms  of  this  inflam- 
matory action,  this  secretion  consists  of  mucus,  which  comes  away 
from  the  ear  as  a  large  mass  of  viscid  white  matter,  somewhat 
analogous  to  that  secreted  by  the  mucous  membrane  of  the  tympanum 
in  cases  of  catarrh  ;  the  difference  being,  that  in  the  case  of  mucous 
from  the  tympanum,  the  circumference  of  the  mass  is  more  fila- 
mentous, the  color  not  so  white,  and  the  substance  less  consistent. 
After  this  discharge  has  continued  for  some  days,  it  loses  its  viscidity, 
and  becomes  milky,  remaining  so  as  long  as  the  affection  continues  to 
be  chronic.  When  the  inflammation  is  not  very  severe,  the  character 
of  the  secretion  is  always  milky,  not  mucous.  There  are  cases  in 
which  the  secretion  is  thin,  and  nearly  as  transparent  as  sermn ;  at 
times  it  is  tinged  with  blood.  The  quantity  of  this  serous  secretion 
astonishes  both  patient  and  medical  man,  I  have  never  had  the 
opportunity  of  collecting  the  secretion,  so  as  to  be  able  to  form  a 
correct  estimate  of  the  quantity  effused  in  twenty-four  hours  ;  but, 
judging  from  the  saturation  of  handkerchiefs,  linen,  and  pillows,  it 
must  amount  to  several  ounces.     The  source  of  this  large  quantity 


90  TIIEDISEASESOFTHEEAR. 

of  secretion  is  the  bloodvessels  of  the  dermoid  meatus,  -wliieli  are 
extremely  numerous,  and  very  large. 

Some  ])atit'iits  are  subject  to  frequent  attacks  of  acute  inflamma- 
tion of  the  meatus,  but  in  them  tlie  symptoms  are  not  very  severe ; 
in  others,  however,  the  inflammation  extends  to  the  bone,  and  thence 
to  the  membranes  of  the  brain.  It  is  not  uncommon  to  see  patients 
in  whom  there  are  some  symptoms  of  cerebral  irritation,  though  not 
of  a  serious  character;  -while,  in  other  instances,  they  are  so  for- 
midable as  to  destroy  life.  These  cases  will  hereafter  be  more  fully 
described. 

Acute  inflammation  of  the  dermoid  meatus  sometimes  occurs  from 
injury,  but  it  usually  subsides  under  the  use  of  leeches  and  fomen- 
tations. 

Tlie  treatment  of  acute  inflammation  of  the  dermoid  meatus  con- 
sists, in  the  milder  cases,  of  the  application  of  evaporating  lotions, 
or  of  hot  fomentations  and  poultices  ;  in  the  more  severe,  leeches 
should  be  applied  to  the  margin  of  the  orifice  of  the  meatus,  so  as  to 
remove  the  blood  directly  from  the  congested  vessels  ;  and  the 
meatus  itself  should  be  syringed  with  hot  water,  the  head  being 
slightly  raised.  The  patient  should  be  kept  in  bed,  perfectly  free 
from  all  noise,  and  small  doses  of  opium  may  be  administered.  After 
the  disappearance  of  the  pain,  the  ear  is  to  be  washed  out  thoroughly 
with  warm  water,  three  or  four  times,  or  even  oftener,  daily;  so  as, 
in  the  first  place,  to  insure  the  removal  of  the  whole  of  the  dis- 
charge, which  is  apt  to  cause  irritation,  and,  in  the  second  place,  to 
act  as  a  warm  bath  to  the  inflamed  membrane.  Unless  there  is  con- 
stitutional del)i]ity,  or  the  ear  has  been  weakened  by  previous  dis- 
ease, the  discliarge  usually  ceases  in  the  course  of  a  few  days  ;  the 
epidermis  is  again  naturalh^  secreted  ;  and  the  power  of  hearing  re- 
turns. Cases  of  acute  inflammation  of  the  dermis  depending  upon 
constitutional  causes,  and  usually  following  nervous  excitement,  re- 
quire to  be  treated  by  tonics  in  addition  to  the  local  applications. 
In  some  cases,  however,  foundation  is  laid  for  chronic  catarrhal  in- 
flammation of  the  dermis,  of  which  I  shall  presently  speak. 


CASES. 

Case  I.  Aciifc  injlammation  of  the  dermoid  vwatus,  arhing  from 
cold. — M.  F.,  Esq.,  aged  26,  a  medical  man,  consulted  me  in  January, 


THE     EXTERNAL     MEATUS.  91 

1853,  on  account  of  great  pain  in  each  ear.  He  said  that  fourteen 
days  previously,  after  being  wet  through,  he  had  an  attack  of  violent 
pain  in  both  ears, — but  especially  in  the  left :  after  twenty-four 
hours'  pain,  discharge  appeared  and  relief  ensued.  The  day  before 
consulting  me,  during  a  journey,  pain  Avas  again  felt  in  each  ear, 
but  more  particularly  in  the  right  :  at  times  the  pain  was  greatly 
aggravated.  On  examination^  the  dermis  of  each  meatus  was  seen 
to  be  very  red  and  SAVollen ;  the  epidermis  was  absent,  but  there  was 
no  discharge.  The  hearing  distance  of  each  ear  was  eighteen  inches. 
An  evaporating  lotion  Avas  applied  on  cotton-wool,  and  the  affection 
subsided. 

Case  II.  Acute  inflammation  of  the  dermis;  cojnous  secretion  of 
mucus. — Miss  M.,  aged  17,  tall,  and  rather  delicate,  consulted  me, 
December  20,  1853,  on  account  of  pain  in  the  right  ear,  accompanied 
with  discharge. 

History. — Ten  days  previously  she  felt  a  slight  pain  in  the  ear, 
which  gradually  increased  so  as  to  interfere  with  her  rest  at  night. 
This  continued  for  eight  days,  though  better  at  times.  Two  days 
previous  to  seeing  me,  a  discharge  appeared  from  the  ear,  and  has 
continued. 

On  examination,  the  meatus  was  seen  to  be  filled  with  discharge, 
which,  when  removed  by  the  syringe,  was  found  to  consist  of  a  large 
white  mass  of  mucus,  about  the  size  of  an  ordinary  horse-bean,  and 
of  scales  of  epidermis.  The  membranous  meatus  was  much  tume- 
fied, its  surface  being  red  ;  the  dermoid  layer  of  the  membrana  tym- 
pani  was  also  red  and  swollen.  The  hearing  distance  was  only  eight 
inches. 

Treatment. — Two  leeches  were  applied  to  the  orifice  of  the  meatus, 
which  was  syringed  out  with  warm  water  twice  daily.  The  pain 
gradually  subsided,  and  in  six  days  the  discharge  had  disappeared. 

Case  III.  Acute  inflammation  of  the  dermis;  great  deafness,  and 
copious  secretion  of  serum. — A.  H.  H.,  Esq.,  aged  38,  of  a  weakly 
constitution,  sent  for  me  in  January,  1854. 

History. — For  three  weeks  he  had  been  suffering  from  an  attack 
of  inflammation  of  the  lungs,  and  four  days  previously,  when  becom- 
ing convalescent,  was  seized  in  the  night  with  a  violent  pain  in  the 
left  ear.  This,  in  spite  of  treatment,  lasted  for  about  twelve  hours, 
when  a  sudden  burst  of  discharge  took  place  from  the  ear,  which 
much  diminished  the  pain.  "When  seen  by  me  on  the  fourth  day 
after  the  discharge  had  appeared,  there  was  still  great  sensitiveness 


92  T  11  E     D  I  S  E  A  S  E  S     0  F     T  II  E     E  A  R. 

of  tlic  meatus,  and  so  great  an  amount  of  deafness,  that  the  watch 
Avas  not  heard  even  when  in  contact  with  the  ear.  On  examination, 
the  dermis  was  found  swollen  and  red,  and  the  dermoid  layer  of  the 
membrana  tympani  in  the  same  state.  So  copious  was  the  secretion 
of  serum,  that  in  half  an  liour  a  white  handkerchief  was  perfectly 
saturated  with  it.  Great  fear  was  felt  lest  the  car  should  have  been 
seriously  injured  by  the  inflammation ;  but  finding  that  the  mem- 
brana tympani  stood  out  naturally,  and  feeling  that  congestion  of 
the  tympanic  mucous  membrane  Avas  quite  suflfiicient  to  produce  the 
deafness,  hopes  were  held  out  that  the  hearing  would  return  as  soon 
as  the  congestion  subsided.  A  leech  was  ordered  to  be  applied  to 
the  margin  of  the  orifice  every  second  day  :  the  meatus  was  syringed 
out  with  warm  water  twice  daily,  and  slight  vesication  was  used  at 
the  back  of  the  ear.  In  the  course  of  three  days  the  discharge  began 
to  subside,  the  pain  ceased,  and  at  the  end  of  ten  days  the  hearing 
was  restored. 

Case  IV.  Frequent  attacks  of  inflammation  of  the  dermis;  hear- 
ing power  natural. — Miss  C,  aged  28,  consulted  me  on  March  7th, 
1854. 

History. — During  two  years  has  been  subject  to  attacks  of  pain 
in  each  ear,  followed  by  discharge,  after  which  there  has  been  an 
intolerable  itching.  Three  months  ago,  she  suffered  from  one  of 
these  attacks  of  pain,  since  which  she  has  had  a  constant  irritation. 
On  examination,  the  dermis  lining  each  meatus  was  observed  to  be 
red  and  swollen.  The  hearing  distance  of  each  ear  was  natural. 
By  applying  leeches  to  the  margin  of  the  orifice  of  the  meatus  the 
irritating  symptoms  disappeared,  and  the  recurrence  of  the  attacks 
of  inflammation  was  prevented. 

ACUTE    INFLAMMATION    OF   THE    DERMOID    MEATUS    EXTENDING 
TO    THE    BRAIN. 

Anatomical  observations. — The  bloodvessels  ramifying  through 
the  membranous  meatus  are  directly  continuous  with  those  entering 
and  supplying  the  osseous  meatus  ;  the  intimate  connection  between 
the  dermis  of  the  meatus  and  the  bone  is  therefore  very  obvious. 
The  relations  of  the  osseous  walls  of  the  external  meatus  to  the 
cavity  of  the  cranium  are  deserving  attention.  In  the  adult,  it  will 
be  found  that  the  upper  wall  of  the  meatus  consists  of  a  solid 
lamina  of  bone,  varying  from  a  line  to  two  lines  in  thickness,  which 


THE    EXTERNAL    MEATUS.  93 

separates  the  cavity  of  the  meatus  from  that  occupied  by  the  middle 
lobe  of  the  cerebrum.  In  some  cases,  a  prolongation  of  the  tym- 
panic cavity  is  found  extending  into  the  substance  of  the  upper  wall 
of  the  meatus.  In  the  child,  these  relations  differ  remarkably  from 
those  just  detailed.  At  birth,  and  for  the  first  year  subsequently, 
the  only  rudiment  of  the  osseous  external  meatus  is  the  superficial 
depression  situated  in  the  middle  of  the  outer  and  lower  part  of  the 
pars  squamosa,  immediately  posterior  to  the  root  of  the  zygomatic 
process.  This  depression,  to  which  the  name  "fossa  auditoria"  may 
be  appropriately  applied,  has  the  rudiments  of  the  mastoid  process 
posterior  to  it  ;  its  surface  is  smoother,  and  its  substance  denser,  it 
also  contains  fewer  foramina  for  the  transmission  of  bloodvessels, 
than  the  surrounding  bone.  At  the  period  of  birth,  the  portion  of 
bone  forming  the  fossa  is  not  more  than  half  or  three-quarters  of  a 
line  thick,  and  the  membranous  meatus  is  attached  to  the  outer,  the 
dura  mater  of  the  middle  cerebral  cavity  to  the  inner  surface.  Its 
structure  is  far  from  being  compact  or  dense,  and  in  its  substance 
the  bloodvessels  from  the  meatus  communicate  with  those  of  the 
dura  mater. 

As  the  bone  approaches  maturity,  the  fossa  assumes  an  oblique 
position,  and  forms  the  upper  wall  of  the  external  auditory  meatus, 
while  it  is  separated  from  the  cavity  of  the  middle  cerebral  fossa  by 
a  dense  layer  of  bone,  into  which  cells  communicating  with  the  tym- 
panic cavity  are  not  unfrcquently  prolonged.  In  the  adult,  the 
fossa  auditoria  has  nearly  lost  its  oblique  direction,  and  become  a 
horizontal  lamina  of  bone. 

From  the  foregoing  remarks,  it  will  be  evident  that  disease  of  the 
membranous  meatus  externus  is  liable  to  extend  to  the  outer  surface 
of  the  bone,  and  thence  to  the  interior.  In  the  only  case  of  fatal 
chronic  disease  which  has  fallen  under  my  notice,  the  disease  ad- 
vanced, posteriorly,  to  the  lateral  sinus. 

Acute  injlammation  of  the  dermoid  meatus  may  arise  from  the 
application  of  cold  to  the  ear,  or  from  the  irritation  of  a  foreign 
body  :  but  neither  cause  is  usually  sufficient  to  produce  extensive 
inflammation  of  the  brain  or  its  membranes,  unless  considerable  con- 
stitutional irritation  coexists. 

For  the  particulars  of  the  following  case  I  am  indebted  to  Dr. 
Nairne,  who  gave  me  the  opportunity  of  dissecting  the  ear. 

Case  V.  Acute  inflammation  of  the  dermis  of  the  external  meatus, 
extending  to  the  brain  and  its  membranes,  caused  by  jJieJcine/  the  ear 


94  THE     DISEASES     OF     THE     EAR. 

with  a  pin. — Mary  Wells,  a  single  -woman,  aged  24,  of  a  scrofulous 
family,  was  attacked  on  the  1st  April,  1841,  with  severe  pain  in  the 
right  ear,  Avhich  for  some  hours  was  distracting,  and  was  followed  by 
a  sensation  of  something  bursting,  and  by  a  discharge  of  blood  and 
water,  that  afforded  immediate  relief.  She  had,  prior  to  this,  suf- 
fered no  pain,  and  could  only  account  for  what  happened  from 
having  picked  her  car  with  a  pin,  to  relieve  a  tingling  in  it.  The 
discharge  was  mixed  with  blood  for  two  days,  and  ceased  entirely  at 
the  end  of  the  week,  when  she  felt  pretty  well.  In  a  few  days, 
however,  she  had  a  rigor,  followed  by  violent  pain  in  the  ear,  which 
lasted  twenty-four  hours,  when  a  copious  purulent  discharge  took 
place,  giving  relief  as  before.  She  was  now  free  from  pain,  and  felt 
in  good  health.  The  discharge  continued  profuse  until  the  24th  of 
April,  when  it  again  ceased.  The  next  day  she  was  seized  with 
violent  pain  in  the  right  ear  and  side  of  the  head,  accompanied  by 
vomiting  and  symptoms  of  general  fever.  As  the  bowels  were  con- 
fined, she  was  purged.  On  the  28th,  the  pain  in  the  head  returned 
with  great  severity,  and  towards  evening  extended  towards  the  right 
ear,  unaccompanied  with  pain  or  redness,  or  increase  of  pain  on 
pressure.  She  vomited  twice.  Ever  since  the  first  attack,  the 
hearing  on  the  right  side  had  been  aff"ected,  and  during  the  last  few 
days  she  had  complained  of  noise  in  the  ear  and  giddiness,  and  car- 
ried her  head  bent  backwards.^  The  pain  increased,  and  on  the  30th 
she  was  admitted  into  St.  George's  Hospital,  and  ordered  a  calomel 
pill  and  haustus  sennte. 

On  the  1st  of  May,  her  state  was  as  follows  : — Pulse  104,  full, 
sharp,  and  compressible ;  tongue  red  and  glazed  ;  the  skin  hot  and 
dry;  the  conjunctiva  slightly  injected.  There  was  slight  intolerance 
of  light,  and  a  peculiar  sensitiveness  of  the  sense  of  touch,  so  that  she 
shrank  from  the  approach  of  a  finger,  though,  when  touched,  she  felt 
no  pain.  Iler  eyes  were  bright,  and  in  constant  motion  ;  the  right 
pupil  was  a  little  more  dilated  than  the  left.  The  respiration  was 
quick  (thirty-two  per  minute).  The  countenance  was  placid,  though 
the  manner  was  rather  hurried.  The  catamenia  were  present.  She 
was  cupped,  had  cold  lotion  applied  to  the  head,  and  calomel  and  a 
black  dose  were  administered.  During  the  following  night  she  was 
delirious,  though  the  senses  could  be  recovered  by  an  effort. 

May  2d,  1  P.M. — There  Avas  a  slight  degree  of  opisthotonos  this 
morning,  and  the  nurse  remarked  that,  on  her  getting  out  of  bed, 

'  Mr.  Mauie,  who  saw  the  patient  two  or  three  time?,  was  of  opinion  that  an  abscess  was 
forming  in  the  internal  ear. 


THE     EXTERNAL     MEATUS.  95 

there  was  a  peculiar  rigidity  of  the  muscles.  She  was,  however, 
quite  comfortable,  and  said  that  the  headache  went  awaj  about  an 
hour  after  the  cupping.  Pulse  120,  sharp  but  compressible  ;  tongue 
red  and  glazed.  She  was  ordered  a  blister  behind  the  right  ear,  and 
three  grains  of  hydragryrum  cum  creta,  were  administered  night  and 
morning. 

3d. — The  feverish  symptoms  were  somewhat  abated,  and  she  had 
some  quiet  sleep  in  the  morning.  The  urine  passed  in  natural  quan- 
tity. 

4th,  1  P.M. — Pulse  again  sharper,  though  the  tongue  was  moist. 
The  eyeballs  were  tender  and  suifused.  No  pain  complained  of,  but 
she  moans  on  being  moved.  The  countenance  is  depressed,  and  she 
throws  the  clothes  off  her ;  she  is,  however,  quite  sensible  when  spoken 
to.  Ice  was  ordered  to  be  applied  to  the  head.  To  proceed  with 
other  medicines. 

3  P.M. — Is  heavier  and  less  sensible. 

6  P.M. — The  ice  was  applied  about  4  o'clock,  soon  after  which  she 
went  into  a  comatose  state,  occasionally,  however,  waving  her  hands, 
and  appearing  to  recognize  her  friends. 

5th,  11  A.M. — Became  perfectly  comatose  about  4  A.M.  She  is 
now  perspiring  profusely.  Pupil  of  right  eye  contracted.  She 
died  at  12. 

Dissection  of  the  body  tivcnty-six  hours  after  death.  The  iveather 
warm.  Head. — There  were  a  few  patches  of  lymph  upon  both 
hemispheres  of  the  brain,  immediately  beneath  the  arachnoid,  which 
was  more  vascular  than  natural.  The  convolutions  of  the  brain 
were  flattened  and  its  substance  was  watery,  but  not  soft,  with  the 
exception  of  the  corpus  callosum,  fornix,  and  the  parts  contained 
in  and  near  the  lateral  ventricles,  which  broke  up  easily  on  a  slight 
touch.  The  cavities  of  the  ventricles  were  large,  and  contained  a 
quantity  of  turbid  fluid.  The  pons  Varolii,  medulla  oblongata, 
and  adjacent  nerves  Avere  smeared  with  concrete,  purulent  lymph, 
effused  into  the  cavity  of  the  arachnoid.  The  cellular  tissue  around 
the  optic  nerves  and  their  union,  contained  pus.  The  cerebellum 
Avas  somewhat  softer  than  natural.  The  dura  mater  coverina:  the 
surface  of  the  petrous  bone  was  very  vascular,  and  its  vessels  were 
distended  Avith  blood  ;  it  Avas  also  separated  from  the  bone  by  a 
small  quantity  of  serous  fluid.  The  substance  of  the  bone  Avas  of  a 
dark  color,  its  bloodvessels  being  distended.  On  examining  the  in- 
ternal ear,  the  membrana  tympani  Avas  found  to  be  entire,  but  both 


96  TIIEDISEASESOFTIIEEAR. 

it  and  the  mucous  meinbane  liiiin<i;  tlie  tympanic  cavity  were  more 
vascular  than  natural.  The  chief"  disease  was  found  in  the  external 
meatus,  of  which  the  membrane  lining  the  inner  third  was  soft, 
highly  vascular,  easily  detached  from  the  bone,  and  covei-ed  by 
purulent  matter.  There  was  no  appearance  of  ulceration  on  the 
surface. 


II.  CuRONic  Inflammation  of  the  Dermis  lining  the  Meatus. 

This  affection  may  be  divided  into — 
[a.)  Simple  Chronic  Inflammation. 
(Z».)  Chronic  Catarrhal  Inflammation. 

{a.)  Simple  chronic  inflammation. 

This  form  of  disease,  without  discharge,  is  frequently  met  with, 
and  is  often  associated  with  a  declining  state  of  health,  though  it 
occasionally  occurs  as  a  purely  local  affection.  One  of  the  most 
common  predisposing  causes  is  residence  in  a  moist  atmosphere.  In 
some  very  obstinate  cases,  change  of  air  has  been  requisite  before 
the  affection  could  be  abated.  The  exciting  causes  appear  to  be  the 
same  as  those  of  acute  inflammation,  viz.,  the  application  of  cold,  or 
of  any  irritating  substance  to  the  meatus  ;  perhaps  the  most  common 
exciting  cause  is  the  habit  of  picking  the  ear  with  some  foreign  body. 
The  symptoms  of  chronic  inflammation  arc  a  feeling  of  distention  in 
the  ear,  often  coupled  with  slight  pain,  or  with  an  intense  itching. 
Sometimes  the  dermis  is  tumefied,  so  that  the  canal  is  diminished  to 
one-half,  or  even  to  one-fourth  of  its  natural  size.  In  other  cases, 
the  dermis  is  scarcely  at  all  swollen,  but  its  free  surface  is  red,  and 
the  epidermis  is  thrown  off  in  large  flakes.  These  flakes  of  epidermis 
accumulate  and  form  large  masses,  which  consist  of  several  layers, 
and  these  masses  are  apt  to  block  up  the  meatus,  and  produce  a 
serious  diminution  of  the  hearing  power.  Occasionally  this  epider- 
mis collects  in  such  large  masses  as  to  dilate  the  meatus,  or  to  cause 
disease  of  the  bone ;  in  other  instances,  it  produces  acute  inflamma- 
tion of  the  dermoid  meatus,  and  of  the  dermoid  layer  of  the  mem- 
bran  a  tympani. 

Treatment. — AVhcn  there  is  hypertro})hy  of  the  dermis,  Avithout 
much  tenderness,  a  solution  of  nitrate  of  silver  (5j  @  SJ)  may  be 
applied  twice  a  week ;  and  slight  counter-irritation  be  kept  up  at 


THE    EXTERNAL    MEATUS.  97 

the  same  time  over  the  mastoid  process.  If  the  surface  of  the  dermis 
is  denuded  of  epidermis  in  parts,  and  more  vascuhir  than  natural, 
the  meatus  should,  in  the  first  place,  be  syringed  with  warm  water, 

Fig.  24. 


Epidermis  from  the  External  Meatus  in  the  form  of  a  tubular  cul-de-sac,  and  a  layer 
arranged  circularly. 

in  order  to  remove  all  the  particles  of  epidermis  which  are  apt  to 
cause  irritation,  and  at  the  same  time  soothe  the  dermis.  While  the 
syringing  is  being  carried  on,  an  astringent  lotion  may  be  applied, 
on  cotton- wool,  to  the  surface  of  the  meatus.  After  the  inflamma- 
tory symptoms  are  subdued,  a  weak  solution  of  nitrate  of  silver 
(gr.  X.  @  Ij)  may  be  applied  twice  daily.  Should  the  epidermis 
continue  to  collect  within  the  meatus,  it  must  be  removed  by  the 
syringe,  which  is  generally  sufficient  for  that  purpose,  notwithstand- 
ing that  the  removal  of  masses  of  epidermis,  on  account  of  its  den- 
sity, and  the  close  way  in  which  one  layer  folds  within  another,  re- 
quires considerable  patience. 


CASES. 

Case  I.  Simple  chronic  inflammation  of  the  dermoid  meatus. — R. 
P.  A.,  Esq.,  aged  47,  in  good  health,  consulted  me  on  July  4,  1853. 

History. — During  the  last  year  and  a  half,  he  has  suffered  at 
times  from  extreme  itching,  with  dulness  of  hearing,  followed  by 
slight  discharge.  Upon  examination,  the  meatus  of  each  ear,  near 
the  orifice,  w\as  found  to  contain  a  large  quantity  of  soft  cerumen  ; 
at  the  middle  part  the  dermis  was  of  a  deep  red  color,  and  the  blood- 
vessels were  enlarged  and  tortuous.  The  hearing  distance  with  the 
right  ear  was  eighteen  inches  ;  with  the  left,  seven. 

Treatment. — Each  meatus  was  washed  out  with  half  a  pint  of 
warm-  water,  twice  daily ;  and  at  night  a  lotion,  consisting  of  a 
solution  of  chloride  of  zinc  in  water  (gr.  ij  @  5j),  was  applied  on 

7 


98  THEDISEASESOFTHEEAR. 

cotton-wool  to  each  meatus.     In  the  course  of  a  fortniirht  he  was 
quite  cured. 

Citse  II.  SimpU  chronic  inflammation,  with  desquamation  of  the 
epidermis. — Miss  E.  P.,  aged  39,  in  a  somewhat  debilitated  state, 
consulted  me  on  July  1,  1853. 

History. — During  the  last  two  or  three  winters,  after  attacks  of 
cold,  had  suffered  a  good  deal  of  pain  in  each  ear,  accompanied  by 
deafness.  The  pain  remains  for  two  or  three  days,  then  a  skin 
comes  away  followed  by  relief  to  the  pain,  and  improvement  in  the 
hearing.  Six  months  *ago  had  a  very  bad  attack,  succeeded  by  dis- 
charge, which  continued  for  a  few  days.  During  the  last  three 
years  has  suffered  from  considerable  irritation  in  the  ears.  On 
examination,  the  meatus  of  each  ear  was  found  red  in  parts — a  red- 
ness that,  on  the  left  side,  extended  to  the  dermoid  layer  of  the 
membrana  tympaiii.  Portions  of  epidermis  adhered  to  the  sur- 
face of  the  dermis  ;  and  when  these  were  removed,  the  dermis  was 
quite  denuded.  The  hearing  distance  of  the  right  ear  was  three 
inches  ;  of  the  left,  one  inch. 

Treatment. — Two  leeches  were  applied  to  the  margin  of  the 
orifice  of  each  meatus  ;  warm  water  was  syringed  into  each  ear  twice 
daily  ;  and,  when  the  congestion  was  diminished,  a  solution  of  nitrate 
of  silver  in  water  (gr.  v.  @  5J)  was  daily  applied  to  both.  A  small 
portion  of  vesicating  paper  Avas  also  applied  over  each  mastoid 
process,  and  tonic  medicines  were  administered.  This  treatment 
afforded  great  relief;  and  when  I  saw  the  patient  again  in  December, 
the  hearing  Avas  very  much  improved,  and  there  was  an  abundant 
secretion  of  cerumen  in  each  ear.  There  had  been  one  attack  in 
the  left  ear  in  the  month  of  August. 

Case  III.  Clironic  inflammation  of  the  dermis,  with  great  hyper- 
trophy.— Miss  T.,  aged  57,  in  tolerable  health,  consulted  me  in 
January,  1853,  on  account  of  great  irritation  and  deafness  in  each 
ear. 

History. — During  the  last  five  or  six  years  has  had  attacks  of 
deafness,  accompanied  by  a  considerable  swelling  in  each  ear.  When 
the  swelling  decreased,  the  hearing  power  partially  returned.  About 
three  weeks  ago  felt  mirch  irritation  in  both  ears,  accompanied,  at 
times,  by  pain  and  much  dulness  of  hearing,  but  not  by  discharge. 
On  examination,  cacli  meatus  was  discovered  to  be  so  tumefied  that 
the  tube  would  only  admit  an  ordinary  sized  probe ;  the  surface  of 


THE     EXTEKNAL     MEATUS.  99 

the  dermis  was  of  a  plum  color :  the  watch  was  not  heard,  except 
when  pressed  on  the  ear. 

Treatment. — Leeches  Avere  ordered  to  be  applied  to  the  orifice  of 
each  meatus,  and  to  be  followed  by  the  use  of  a  solution  of  nitrate 
of  silver  (5ss  @  oj).     I  did  not  hear  the  result. 

Case  IV.  Chronic  inflammation  of  the  dermoid  meatus  ;  accumu- 
lation of  epidermis. — The  Rev.  G.  T.,  aged  55,  consulted  me  in  July, 
1850,  on  account  of  pain  in  the  left  ear,  with  accompanying  deafness. 

History. — During  several  months  has  had  a  tenderness  in  the  left 
ear,  with  a  sensation  of  fulness,  and  a  diminution  of  the  hearing 
power:  latterly  these  symptoms  have  increased.  On  examination, 
the  surface  of  the  outer  half  of  the  meatus  was  observed  to  be  red, 
and  somewhat  tumefied,  and  the  inner  half  was  completely  full  of 
epidermis.     Hearing  distance  with  the  watch,  two  inches. 

Trcat?nent. — The  collection  of  epidermis  was  removed  by  the 
syringe  and  warm  water.  This  operation,  however,  required  the 
greatest  care,  on  account  of  the  extreme  tenderness  of  the  surface 
of  the  meatus ;  even  the  ordinary  stream  of  water  from  the  syringe 
being  productive  of  great  pain.  After  the  removal  of  the  collection, 
the  hearing  power  was  greatly  improved.  The  surface  of  the  dermis 
being  red,  a  weak  solution  of  nitrate  of  silver  was  applied  to  the  sur- 
face of  the  meatus  twice  a  week,  which  effected  further  improve- 
ments ;  but  the  epidermis  again  collected.  After  its  removal,  mild 
astringents  were  used,  and  the  ear  was  syringed  frequently  with 
warm  water,  which  diminished  the  inflammation,  but  the  epidermis 
still  continues  to  collect,  and  requires  removal  by  the  syringe  every 
two  or  three  months.  The  moist  atmosphere  in  which  this  patient 
lives,  is  probably  a  cause  of  the  unyielding  character  of  the  affection. 

(5.)    Chkonic    catarrhal    inflammation    of    the    dermoid 

MEATUS. 

This  disease  has  been  frequently  classed  among  the  cases  of  otor- 
rhoea.  As  its  name  implies,  it  consists  of  chronic  inflammation  of 
the  dermoid  meatus,  with  accompanying  discharge.  In  many  in- 
stances, the  disease  is  confined  to  the  meatus  ;  but  in  others,  it 
advances  to  the  dermoid  layer  of  the  mcmbrana  tympani.  It  most 
commonly  occurs  in  children  ;  though  by  no  means  rare  in  adults. 
In  childhood,  it  is  usually  accompanied  by  a  tendency  to  glandular 
enlargements  or  some  other  sign  of  constitutional  debility.  In  the 
adult,  it  is  also  too  often  symptomatic  of  a  depressed  state  of  health. 
The  exciting  cause  may  be  an  attack  of  acute  inflammation  of  the 


100  THE     DISEASES     OF     THE    EAR. 

dermis,  an  injury,  the  use  of  stimulating  applications,  or  attacks  of 
measles,  scarlatina,  or  catarrh.  Often  this  affection  has  no  assign- 
able cause,  and  appears  with  a  sliglit  itching  in  the  ear  ;  sometimes, 
indeed,  the  appearance  of  discharge  is  the  first  indication  of  diseased 
action.  In  the  early  stages,  there  is  usually  but  little  diminution 
of  the  power  of  hearing,  even  •when  the  inflammation  and  hyper- 
trophy extend  to  the  dermoid  layer  of  the  membrana  tympani. 
When  the  disease  has  remained  for  some  time,  the  mucous  mem- 
brane of  the  tympanum  is  apt  to  participate,  and  deafness  to  result. 
It  must,  however,  be  borne  in  mind,  that  catarrh  of  the  dermoid 
meatus,  and  of  the  dermoid  layer  of  the  membrana  tympani,  are 
frequently  symptomatic  of  irritation  within  the  tympanic  cavity, 
and  that  these  exterior  symptoms  cease  as  soon  as  the  internal  irri- 
tation is  overcome.  In  these  cases  of  sympathetic  catarrh  of  the 
dermoid  meatus,  there  is  usually  a  history  of  previous  irritation  in 
the  tympanum,  and  much  dulncss  of  hearing  commonly  precedes  the 
appearance  of  the  discharge.  After  this  affection  has  persisted  some 
time,  there  is  often  a  great  degree  of  irritation  in  the  meatus ;  some- 
times there  is  pain,  and  now  and  then  a  discharge  of  blood.  The 
latter  symptom,  however,  is  more  common  where  a  polypus  is  pre- 
sent. 

On  examination  of  cases  of  catarrh  of  the  dermoid  meatus,  the 
dermis  is  generally  found  thicker  than  natural  ;  sometimes  so  much 
so  as  nearly  to  close  the  tube.  While  in  some  cases  the  surface 
(denuded  of  epidermis)  is  red,  in  others  it  is  blanched.  The  dis- 
charge has  usually  a  very  offensive  odor  ;  and  its  hue  varies  from 
milky  white  to  dark  slate  color.  The  peculiarity  of  this  discharge 
is,  that  Avhatever  may  be  its  quantity,  color,  or  consistence,  there 
are  no  masses  of  mucus  floating  in  it :  but  it  mixes  freely  with 
water,  producing  a  general  opacity.  In  cases,  however,  in  which  a 
polypus  coexists  with  this  form  of  inflammation,  the  discharge  con- 
tains flocculent  mucus,  as  also  in  cases  of  ulceration  of  the  fibrous 
laminae  of  the  membrana  tympani :  sometimes  there  is  also  discharge 
of  blood.  Wiicn  chronic  catarrhal  inflammation  extends  to  the  der- 
moid layer  of  the  membrana  tympani,  the  structure  of  this  mem- 
brane, like  that  of  the  dermoid  meatus,  becomes  hypertrophicd,  and 
often  mucli  congested  ;  the  membrane  itself  loses  both  its  natural 
color  and  form  ;  its  outer  surface  is  flattened  ;  while  the  processus 
longus,  an<l  frequently  the  processus  brevis,  are  completely  con- 
cealed bv  it. 


THE     EXTERNAL    MEATUS.  101 

The  treatment  of  chronic  catarrh  of  the  dermoid  meatus  consists 
in  the  efficient  and  frequent  use  of  the  syringe  and  warm  water,  to 
thoroughly  remove  the  discharge,  and  cleanse  the  tube.  Should 
there  be  symptoms  of  pain  or  irritation,  one  or  two  leeches  should  be 
applied  to  the  margin  of  the  orifice  of  the  meatus,  and  be  followed 
by  the  use  of  warm  fomentations,  steam-baths,  or  poultices.  On  the 
disappearance  of  the  irritation,  weak  astringent  injections  may  be 
used,  and  slight  counter-irritation  be  kept  up  over  the  mastoid  pro- 
cess. These  measures,  coupled  with  the  administration  of  tonic 
medicines,  and  attention  to  the  general  health,  will  frequently  put 
a  stop  to  the  affection.  In  more  obstinate  cases,  it  is  requisite  to 
keep  up  a  discharge  over  the  mastoid  process  by  means  of  vesication 
or  croton  oil  liniment:  a  solution  of  nitrate  of  silver  (10  to  40  grains 
to  the  ounce)  should  also  be  applied  to  the  surface  of  the  meatus 
every  third  day.  Some  cases,  in  spite  of  all  remedies,  are  but 
slightly  ameliorated,  after  two  or  three  months'  treatment ;  it  is, 
notwithstanding,  of  great  importance  that  the  treatment  be  perse- 
vered in  to  prevent  the  supervention  of  caries  of  the  bones,  ulcera- 
tion of  the  membrana  tympani,  and  the  development  of  polypus. 

Case  V.  Chronic  catarrhal  inflammation  of  the  dermoid  meatus 
during  teething. — J.  A.,  aged  nine  months,  pale,  and  weakly,  was 
admitted  under  my  care  at  St.  Mary's  Hospital,  in  November,  1854, 
on  account  of  an  offensive  discharge  from  the  left  ear. 

History. — The  mother  stated,  that  about  two  months  previously, 
when  the  child  was  irritable  and  restless  from  teething,  a  discharge 
took  place  from  the  left  ear.  Small  at  first,  the  quantity  had  gra- 
dually increased  and  become  very  offensive. 

On  examination,  the  left  external  meatus  was  seen  to  be  full  of  a 
Avhite  milky  discharge,  that,  when  the  ear  was  syringed,  mixed  with 
the  water,  Avhich  became  opaque  and  milky,  and  masses  of  epidermis 
floated;  but  there  was  no  appearance  of  mucus.  After  the  discharge 
had  been  removed,  the  calibre  of  the  tube  was  observed  to  be  dimi- 
nished one-half  by  the  swelling  of  the  dermis,  whose  inner  surface 
was  denuded  of  epidermis  and  somewhat  redder  than  natural :  the 
dermoid  layer  of  the  membrana  tympani  was  flat  and  white. 

Treatment. — Daily  exercise  in  the  open  air  was  ordered,  and  cod- 
liver  oil  administered.  The  surface  of  the  body  was  to  be  sponged 
daily  with  tepid  water,  and  the  ear  to  be  syringed  out  with  warm 
water  twice  daily,  and  a  solution  of  chloride  of  zinc  (one  grain  to  an 
ounce  of  water)  to  be  applied  on  cotton  to  the  tube  of  the  ear  during 


102  THE    DISEASES     OF    THE     EAR. 

the  night.  The  health  of  the  child  soon  greatly  improved,  the  quan- 
tity of  discharge  diminished,  and,  in  six  weeks,  entirely  ceased. 

Case  YI.  Catarrh  of  the  dermis  in  both  ears  of  a  child,  causing 
dulness  of  hearing. — Master  E.  M.,  aged  three  years  and  a  half, 
was  brought  to  me  on  April  6,  1855,  on  account  of  a  discharge  from 
the  ear,  with  dulness  of  hearing.  He  was  pale  and  thin,  his  general 
health  not  good,  and  he  was  subject  to  enlargements  of  the  cervical 
glands. 

History. — About  two  years  previously,  without  assignable  cause, 
a  discharge  suddenly  flowed  from  the  right  ear,  and  after  another 
month  the  left  ear  was  similarly  affected ;  the  discharge  being  abun- 
dant and  the  odor  very  off"ensive.  After  continuing  for  three  or 
four  months,  the  discharge  disappeared  from  both  ears  ;  but  about 
a  month  before  consulting  me,  it  had  reappeared  with  the  same  symp- 
toms as  at  first. 

On  examination,  each  meatus  was  found  full  of  milky  discharge, 
and  rod  on  the  surface  :  the  substance  of  the  dermis  swollen.  The 
dermoid  layer  of  the  membrana  tympani  Avas  red  and  thick.  The 
hearing  power  was  so  diminished  that  he  required  to  l^e  loudly  spoken 
to  at  the  distance  of  two  yards.  The  watch  was  unheard  except 
when  in  contact  with  the  right  ear,  or  when  pressed  upon  the  left. 
It  was  evident  that  inflammation  had  extended  to  the  tympanic 
cavity  as  well  as  to  the  membrana  tympani. 

Treatment. — Both  ears  to  be  washed  out  with  tepid  water  thrice 
daily,  and  afterwards  to  be  syringed  with  a  solution  of  acetate  of 
zinc  (five  grains  to  the  ounce) ;  a  portion  of  vesicating  paper  to  be 
applied  over  each  mastoid  process  every  second  night,  and  two  tea- 
spoonfuls  of  steel  wine  to  be  given  twice  daily.  This  treatment  in 
two  months  produced  considerable  benefit,  the  (quantity  of  discharge 
diminished,  and  the  power  of  hearing  improved.  This  improvement, 
however,  did  not  continue,  and  at  the  end  of  the  year  I  saw  him 
much  in  the  same  state  as  when  first  brought  to  me.  I  then  found 
that  the  syringing  had  been  very  imperfect,  a  large  quantity  of  dis- 
charge being  left  in  the  ears  after  the  operation.  Strict  attention 
to  this  point  was  enjoined  ;  a  solution  of  nitrate  of  silver  (gr.  x.  @ 
5J)  was  applied  to  the  surface  of  the  dermis  by  means  of  a  camel's 
hair  pencil,  night  and  morning  ;  the  vesicating  paper  was  again  used, 
and  cod-liver  oil  prescribed.  This  treatment  having  been  pursued 
for  three  months,  the  discharge  had  ceased,  although  the  power  of 
hearing  was  not  wliollv  restored. 


THE     EXTERNAL     MEATUS.  103 

Case  Yll.  Chronic  catarrhal  inflammation  of  the  dermis:  great 
irritation. — Mrs.  A.,  aged  30,  consulted  me  in  August,  1856.  She 
was  in  tolerable  healtli. 

History. — Two  years  previously  she  experienced  at  times  great 
irritation  and  pain  in  the  tube  of  each  ear,  followed  by  discharge  : 
thinks  the  affection  was  caused  by  residence,  in  a  damp  house  ;  it 
was  aggravated  by  exposure  to  cold  air.  Since  the  above  period 
has  had  several  similar  attacks,  and  the  ears  are  never  quite  free 
from  itching  and  discharge.  The  power  of  hearing  has  not  been 
diminished. 

On  examination,  the  surface  of  the  dermis  in  both  ears  was  found 
denuded  of  epidermis,  red,  slightly  tumefied,  and  covered  by  a  mu- 
cous discharge.  Each  membrana  tympani  was  healthy.  The  hear- 
ing was  natural. 

Treatment. — As  there  was  evidently  much  congestion,  two  leeches 
were  applied  to  the  margin  of  the  orifice  of  each  meatus,  and  both 
ears  syringed  with  warm  water  twice  daily.  In  the  course  of  a  week, 
the  congestion  having  much  diminished,  a  solution  of  nitrate  of  silver 
(gr.  vj  @  5J)  was  applied  to  the  surface  of  each  meatus  by  means  of 
a  camel's  hair  brush,  twice  daily.  Under  this  treatment,  and  the 
occasional  use  of  the  syringe  with  warm  water,  the  irritation  sub- 
sided and  the  discharge  disappeared.  The  affection,  however,  was 
slightly  reproduced  by  a  continuance  of  damp  weather,  or  a  reduc- 
tion of  the  state  of  health  ;  but  speedily  subsided  under  treatment. 

Case  VIII.  Chronic  catarrh  of  the  7neatus  extei'nus  after  scarlet 
fever,  accompanied  by  j^^'^'^^  ^'^^  t^^^  head. — E.  D.,  aged  7,  Avas  ad- 
mitted under  my  care  at  St.  George's  and  St.  James's  Dispensary 
on  the  21th  February,  1815.  At  three  years  old,  he  had  an  attack 
of  scarlet  fever,  followed  by  ear-ache  and  discharge  from  each  ear : 
after  every  attack  of  pain,  discharge  appeared.  At  present,  and 
for  the  last  two  years,  has  complained  of  pain  at  the  back  of  the 
head.  On  examination,  the  membranous  meatus  of  each  ear  Avas 
found  red,  thicker  than  natural,  and  pouring  out  a  milky  secretion. 
Each  membrana  tympani  was  opaque,  and  its  dermoid  layer  thick 
and  vascular.  The  treatment  consisted  in  the  frequent  use  of  the 
syringe  and  warm  water,  the  application  of  a  leech  now  and  then  to 
the  margin  of  the  orifice  of  the  meatus,  and  tonic  medicines.  At 
the  end  of  ten  weeks  under  this  plan  the  hearing  greatly  improved, 
and  the  symptoms  of  pain  in  the  head  disappeared. 


10-1  THE    DISEASES     OF    THE    EAR. 

(c.)  Chronic  catarrhal  inflammation  of  the  dermoid  mea- 
tus EXTENDING  TO  THE  BRAIN. 

It  is  not  common  for  chronic  catarrhal  inflammation  to  extend  to 
the  bone  and  the  brain  ;  at  least  I  have  met  with  but  one  well- 
marked  case,  in  which  death  was  the  result. 

Case.  IX.  Catarrhal  injlammation  of  the  dermoid  layer  of  the 
external  meatus,  with  caries  of  the  jJosterior  ivall ;  disease  extending 
to  the  lateral  sinus  and  cerebellum. — Harriet  Baker,  aged  three 
years  and  a  half,  was  admitted  under  my  care  at  the  St.  George's 
and  St.  James's  Dispensary,  on  the  6th  December,  1848.  Her 
motlier  stated  that  the  child  had  always  been  sickly ;  and  at  five 
months  old  a  thick  creamy  discharge  had  been  seen  to  ooze  from 
the  left  ear,  which,  though  not  abundant,  was  very  ofiensive.  The 
child  had  not  till  recently  complained  of  pain,  but  now  and  then 
asked  to  have  the  ear  picked,  because  of  its  itching.  Three  weeks 
ago  the  discharge  ceased,  violent  pain  ensued  in  the  ear,  with  a 
swelling  over  the  region  of  the  mastoid  and  squamous  processes, 
which  caused  the  car  to  project  from  the  side  of  the  head  :  great 
restlessness  and  delirium  followed,  and  she  was  constantly  throwing 
herself  iibout. 

On  examination,  the  surface  of  the  dermis  was  red  and  denuded 
of  epidermis;  it  was  smooth  but  not  ulcerated,  and  much  thicker 
than  natural,  so  that  the  cavity  of  the  meatus  was  only  one-third 
of  its  proper  calibre.  The  membrana  tympani  was  absent.  The 
abscess  behind  the  ear  had  opened ;  and  about  a  wine-glassful  of 
pus,  of  a  most  offensive  odor,  having  been  discharged,  the  sur- 
face of  the  squamous  and  mastoid  processes  was  felt  to  be  rough 
and  carious.     Linseed-meal  poultices  were  applied. 

Dec.  9th. — The  discharge  continues  very  copious  ;  the  pain  and 
tumefaction  have  extended  to  the  temporo-maxillary  articulation,  so 
that  the  jaw  can  be  opened  but  a  very  little  way. 

14th. — The  discharge,  lately  so  abundant,  has  now  ceased,  while 
the  pain  and  restlessness  have  greatly  increased  ;  the  hands  liave 
been  kept  applied  to  the  head. 

The  head-symptoms  continued  to  increase  till  the  29th,  when  the 
patient  died  in  a  state  of  great  emaciation. 

Post-mortem  inspection. — On  removing  the  calvarium,  the  dura 
mater  appeared  healthy,  as  well  as  the  arachnoid  and  pia  mater. 
The  lateral  ventricles  contained  about  half  an  ounce  of  perfectly 
clear  serum.     Upon  the  removal  of  the  cerebrum  there  was  no  ap- 


THE    EXTERNAL     MEATUS. 


105 


pearance  of  disease  ;  the  dura  mater  and  arachnoid  covering  the 
upper  part  of  the  left  petrous  hone  were  quite  healthy.  When  the 
tentorium  was  removed,  the  left  hemisphere   of  the  cerebellum  was 


Fig.  25. 


The  Internal  Surface  of  the  Temporal  Bone,  showing  the  two  orifices  in  the  Lateral  Sinus 
which  were  filled  by  the  cerebellum,  and  also  showing  the  carious  Sulcus  Lateralis. 

observed  to  be  much  softer  than  natural,  and  the  portion  in  contact 
Avith  the  posterior  surface  of  the  pars  petrosa  was  dark  in  color  and 
very  soft.  Upon  gently  drawing  it  backwards,  it  was  found  to  be 
applied  against  two  orifices  in  the  posterior  part  of  the  lateral  sinus, 
and  to  be  separated  from  the  cavity  of  the  sinus  by  the  thickened 
arachnoid  and  pia  mater.  A  considerable  vessel  in  the  pia  mater, 
opposite  the  orifice,  was  distended  by  a  firm  and  dark  coagulum, 
half  an  inch  in  length.  The  anterior  membranous  wall  of  the 
lateral  sinus  was  absent ;  the  bone  forming  the  sulcus  lateralis  in 
the  mastoid  process  was  carious,  and  the  sinus  full  of  a  dark-colored 
coagulum  and  purulent  matter  ;  pus  was  also  found  in  the  jugular 
veins. 

The  ear. — The  dermis  lining  the  whole  of  the  external  meatus 
was  soft,  tumefied,  and  dark-colored,  and  its  surface  Avas  devoid  of 
epidermis  ;  beneath  it,  posteriorly,  Avas  purulent  matter,  Avhich  sepa- 
rated it  from  the  carious  bones.  The  membrana  tympani  Avas  absent ; 
but  there  Avas  no  more  appearance  of  disease  in  the  tympanic  cavity 
than  might  have  been  produced  by  the  afi"ection  of  the  meatus.     The 


100 


THE    DISEASES    OF    THE     EAR, 


bone  was  carious  anteriorly  as  far  as  the  root  of  the  zygomatic  pro- 
cess and  the  fossa  for  the  articuhition  of  the  lower  jaw  ;  superiorly 
and  posteriorly,  the  caries  extended  for  the  distance  of  an  inch  and 


Fig.  26. 


The  External  Surface  of  the  Temporal  Bone,  showing  the  carious  portion  extending  from 
the  Mastoid  Process  posteriorly  to  the  root  of  the  Zygomatic  Process  anteriorly. 

a  quarter,  nearly  to  the  margin  of  the  parietal  bone  ;  but  in  some 
parts  the  external  table  only  Avas  affected,  while  in  others  it  ex- 
tended to  the  diploe  and  thence  to  the  internal  table.  On  holding 
the  bone  up  to  the  light,  small  orifices  were  seen  through  it ;  so  that 
its  external  surface,  or  that  part  which  was  covered  by  the  mem- 
branous meatus,  was  directly  continuous  with  the  lateral  sinus. 

The  progress  of  the  disease  in  this  case  from  without  inwards,  is  very 
remarkable;  for  there  is  no  evidence  to  prove  that  the  disease  origina- 
ted elsewhere  than  in  the  meatus  ;  and  it  is  apparent,  from  the  direct 
communication  by  bloodvessels  between  the  membranous  meatus 
and  the  bone  forming  the  lateral  sinus,  that  disease  could  easily  be 
transferred  from  the  inflamed  meatus  to  the  bone  beneath.  Careful 
consideration  of  the  subject  has,  however,  induced  me  to  believe  that 
the  progress  of  disease  from  the  meatus,  inwards,  to  the  internal 
sinus  and  cerebellum,  is  of  rare  occurrence  ;  and  to  think  that  the 
majority  of  the  cases  of  this  kind  recorded  as  having  oc(?urred  to 
previous  inquirers,  were  really  instances  of  disease  advancing  from 
the  tynipanic  cavity  or  mastoid  cells  outwards,  to  the  meatus,  in 
which  process  the  cerebellum  and  lateral  sinus  were  implicated. 

Treatment. — I  have  already  stated  it  to  be  my  opinion,  founded 


THE    EXTERNAL    MEATUS.  107 

on  a  consideration  of  some  of  the  cases  already  adduced,  that  when 
a  disease  of  the  brain  originates  in  a  chronic  affection  of  the  ear, 
the  cause  of  its  prolongation  to  the  brain  may  be  traced  to  the  want 
of  a  free  egress  for  the  matter. 

The  modes  in  which  this  matter  may  be  confined  are  various.  In 
the  case  of  the  external  meatus,  the  tumefied  walls,  together  Avith  its 
peculiar  valvular  disposition  as  seen  in  infants,  create  a  sufficient 
barrier  to  the  free  egress  of  the  secretion.  In  the  tympanic  cavity, 
the  matter  is  usually  retained  by  the  membrana  tympani,  Avhicli 
either  Avholly  or  partially  prevents  its  escape  ;  sometimes,  however, 
the  hypertrophy  of  the  mucous  membrane  is  itself  sufficient  to  shut 
up  the  secretion  in  parts  internal  to  it ;  and  occasionally  even  the 
thick  accumulated  matter  itself  may  prove  a  bar  to  the  egress  of 
that  which  is  beyond  it.  In  the  case  of  the  mastoid  cells,  it  appears 
that  the  matter  may  be  retained  by  the  peculiar  position  of  their 
horizontal  portion,  the  floor  of  Avhich  is  often  below  that  of  the 
orifice  into  the  tympanum  ;  or  it  may  occupy  the  vertical  portion  of 
the  cells,  Avhicli  is  quite  beloAV  the  part  leading  into  the  tympanum. 
The  rules  to  be  laid  doAvn  in  the  treatment  of  chronic  catarrh  of  the 
dermoid  meatus,  the  mucous  membrane  of  the  tympanum,  and  the 
mastoid  cells,  are  as  follow  : — 

1.  By  attention  to  the  general  health  to  attempt  to  diminish  the 
catarrh. 

2.  To  secure,  if  possible,  a  free  exit  for  the  secreted  matter. 

3.  By  keeping  up  an  external  discharge,  to  cause  that  within  the 
ear  to  be  absorbed ;  and  thus  to  arrest  further  secretion,  and  allay 
the  diseased  action. 

General  Treatment. — As  far  as  general  measures  go,  the  same 
observations  will  apply  to  the  diseases  of  each  of  the  different  parts 
of  the  ear.  As  it  seems  probable  that  the  usual  predisposing  cause 
of  these  diseases  is  a  scrofulous  diathesis,  every  means  should  be 
taken  to  invigorate  the  health.  Abundant  exercise  in  the  open  air, 
especially  in  the  country  or  by  the  sea-side,  simple,  nutritious,  but 
not  stimulating  diet,  and  mild  tonic  medicine,  are  to  be  specially 
recommended.  Great  care  should  be  taken  that  the  patient  sleeps 
in  a  Avell-ventilated  room,  in  a  bed  without  curtains,  the  head  being 
kept  high  and  cool,  and  above  the  bed-clothes.  Everything  which 
is  liable  to  excite  must  be  sedulously  avoided  ;  and  rough  play,  in 
which  the  head  is  apt  to  receive  a  blow,  must  not  be  allowed.  From 
whatever  source  the  discharge  comes,  it  is  desirable,  when  practi- 


108  THE    DISEASES     OF    TUE    EAR. 

cable,  that  the  membrane  whence  it  issues  should  be  washed  fre- 
quently with  tepid  water ;  hence  the  use  of  the  syringe  is  of  great 
importance.^  When  there  is  congestion,  the  application  of  one  or 
two  leeches  is  desirable,  and  sometimes  gentle  counter-irritation 
should  be  resorted  to.  This  may  be  eflfected  by  a  liniment  to  be 
rubbed  over  or  around  the  ears  and  down  the  spine.  Gentle  astrin- 
gents may  also  be  used.  "Whatever  may  be  the  source  of  the  dis- 
charge, as  a  general  rule,  its  continuance  for  some  months  after  the 
exciting  cause  is  symptomatic  of  a  scrofulous  or  otherwise  unhealthy 
diathesis ;  and,  in  spite  of  every  effort,  the  hypertrophied  membrane 
is  but  very  slowly  affected,  and  consequently  the  discharge  is  gene- 
rally of  long  duration.  It  is  important,  however,  that  the  medical 
man,  knowing  the  exact  nature  of  the  disease,  and  its  peculiarly 
chronic  character,  should  inform  the  parents  or  friends  of  the  patient 
that  any  attempt  to  stop  the  discharge  by  powerful  astringents,  or 
otherwise  than  by  gentle  means,  may  be  attended  with  serious  con- 
sequences, as  the  production  of  acute  inflammation.  Here,  perhaps, 
I  may  be  excused  a  few  words  on  a  subject  so  frequently  adverted 
to  as  the  danger  of  stopping  a  discharge  from  the  ear.  The  sup- 
posed danger  of  an  arrest  of  the  discharge  by  local  applications 
seems  to  have  originated  in  the  knowledge  of  the  fact,  that  one  of 
the  most  common  symptoms  in  the  early  stages  of  acute  inflamma- 
tion of  the  ear,  following  upon  a  chronic  disease,  is  the  cessation  of 
the  discharge  which  previously,  and  often  for  many  years,  had  been 
constant.  There  can  be  no  doubt  that  in  these  cases  the  cessation 
of  the  discharge  is  one  of  the  effects,  and  not  one  of  the  causes  of 
the  inflammation  ;  for  other  symptoms  of  inflammatory  action  may 
usually  be  observed  before  the  discharge  disappears.  In  cases 
where  strong  astringents  have  been  employed  in  order  to  arrest  a 
discharge  from  the  ear,  the  symptoms  that  follow  are  not  dependent 
upon  the  cessation  of  the  discharge  (for,  indeed,  the  discharge  does 
not  always  diminish),  but  upon  the  inflammation  caused  by  the  irri- 
tant. 

To  sum  up  what  has  been  said  respecting  the  general  treatment, 

'  Many  of  the  syringes  in  common  use  are  very  inefficient,  as  tbey  do  not  send  the  water 
into  the  ear  with  sufficient  force  to  remove  the  discharge.  The  best  and  most  simple  for 
patients  to  use,  is  the  four  ounce  vulcanized  india  rubber  bottle,  made  by  Bell  &  Co.  The 
metal  nozzle  should  be  made  so  as  to  allow  of  being  easily  removed.  When  the  syringe  is 
to  be  filled,  the  nozzle  should  be  taken  rut,  and  the  fluid  to  be  injected  should  be  poured 
into  the  bottle  ,  or  it  may  be  allowed  to  fill  itself,  the  air  having  been  previously  expelled 
by  pressing  the  sides  together. 


THE     EXTERNAL     MEATUS.  109 

where  there  is  simple  chronic  catarrh  from  the  dermoid  meatus,  mem- 
brana  tympani,  or  the  tympanic  mucous  membrane,  with  free  egress 
for  the  matter  :  when  there  are  symptoms  of  congestion,  apply  one 
or  tAvo  leeches  near  the  part  aftected  ;  syringe  the  ear  frequently 
Avith  an  abundant  supply  of  Avarm  Avatcr ;  use  mild  astringent  lotions, 
and  endeaA'or  to  improve  the  health  by  every  means  possible  to  the 
patient.  In  face  of  all  these  measures,  the  medical  man  may  expect 
to  see  the  disease  make  very  sIoav  progress  toAA'ards  amelioration  ; 
but  he  must  be  content  that  its  advance  iuAvards  toAvards  the  bone 
and  the  brain  is  averted. 

In  cases  of  catarrh  of  the  dermoid  meatus  there  is  A^ery  frequently 
some  source  of  irritation  of  the  tympanic  mucous  membrane,  of 
which  the  catarrh  of  the  meatus  is  but  a  symptom.  Thus  it  is  not 
uncommon  to  find  obstruction  of  the  Eustachian  tube,  even  at  the 
faucial  orifice,  attended  by  catarrhal  inflammation,  and  even  by 
polypus  in  the  meatus ;  both  of  Avhich  secondary  affections  wholly 
disappear  Avhen  the  primary  disease  is  removed.  Cases  of  simple 
catarrh  of  the  dermoid  meatus  do,  hoAvever,  occasionally  occur :  and 
one  Avhich  terminated  fatally  has  already  been  cited.  As  a  general 
rule  they  may  be  distinguished  from  the  secondary  cases  by  the 
absence  of  all  appearance  of  disease  in  the  tympanic  cavity  ;  by  the 
power  of  hearing  being  but  slightly  aff'ected,  and  by  the  healthy 
state  of  the  membrana  tympani,  except  an  occasional  increased 
vascularity  of  its  dermoid  layer.  Primary  catarrh  from  the  dermoid 
layer  usually  occurs  in  children  suff"ering  from  debility ;  when  the 
dermis,  instead  of  secreting  its  epidermis,  pours  forth  a  Avatery  fluid 
composed  of  serum,  in  Avhich  float  epidermoid  cells  in  different  stages 
of  development.  This  discharge  has  often  an  extremely  offensive 
odor,  dependent  generally,  not  upon  the  presence  of  dead  bone, 
but  upon  a  deranged  action  of  the  ceruminous  glands.  The  discharge 
from  the  meatus,  in  cases  of  chronic  catarrh,  diff"ers  from  that  which 
attends  the  same  affection  in  the  tympanum  in  the  Avay  already 
pointed  out ;  and  it  usually  subsides  under  the  use  of  a  syringe  and 
tepid  Avater,  tonic  medicine,  and  the  ordinary  plans  for  strengthening 
the  constitution  of  the  patient.  When  the  health  is  much  deranged, 
it  may  take  some  months  to  eff'cct  a  cure ;  but  during  the  Avholc  of 
this  period  daily  syringing  must  be  practised. 

(d.)  Ulceration  of  the  dermoid  meatus. 

Cases  of  catarrh  of  the  dermoid  meatus,  if  neglected,  may  advance 
to  ulceration ;  the  bone  mav  become  diseased,  and  a  small  osseous 


110  THE     DISEASES     OF     THE     EAR. 

lamina  may  eventually  be  discharged ;  but  ulceration  of  the  soft 
meatus  usually  arises  from  the  pressure  of  dead  bone  from  the  mas- 
toid cells  making  its  way  tlirough  the  orifice  of  the  meatus. 

Besides  the  ulceration  of  the  dermis,  alluded  to  above,  as  resulting 
from  disease  of  the  bone,  a  second  kind  of  ulceration,  viz.,  having  a 
syphilitic  character,  is  also  met  with.  Its  local  treatment  does  not 
differ  from  that  pursued  in  other  ulcerations  of  the  dermoid  structure. 


CHAPTER   VI. 

THE  EXTERNAL  MEATUS  {continued). 
POLYPI. 

CAUSES  OF  POLYPUS  SYMPTOMS — THREE  SPECIES  OF  POLYPUS:  1.  THE  CELLULAR  RASP- 
BERRY POLYPUS — STRUCTURE — TREATMENT  WITH  POTASSA  CUM  CALCE — CASES — TREAT- 
MENT BY  REMOVAL  WITH  THE  LEVER-RING  FORCEPS — CASES.  2.  THE  FIBRO-GELATINOUS 
POLYPUS — STRUCTURE — TREATMENT — CASES.  3.  THE  GLOBULAR  CELLULAR  POLYPUS 
— STRUCTURE — TREATMENT — CASES. 

Polypi. — Polypoid  groAVths  are  not  unfrequently  met  with  in  the 
meatus,  and,  as  already  stated,  are  generally  the  result  of  long-con- 
tinued irritation  of  its  dermoid  layer;  sometimes,  however,  they 
arise  from  chronic  inflammation  of  the  mucous  membrane  of  the 
tympanum,  or  from  obstruction  of  the  Eustachian  tube.  As  a  rule, 
polypi  are  attached  to  the  surfiice  of  the  dermoid  layer  of  the  meatus, 
although  I  have  met  with  cases  in  which  they  sprang  from  the  outer 
surface  of  the  membrana  tympani,  and  in  one  dissection  I  found 
what  appeared  to  be  a  polypus  growing  from  the  inner  surface  of 
the  latter.  The  existence  of  a  polypus  is  always  attended  with  a 
discharge  of  matter ;  arising  usually  from  two  sources, — the  dermoid 
layer  of  the  meatus,  and  the  surface  of  the  polypus  itself.  In  some 
cases  there  is  a  flow  of  blood,  and  generally  a  very  offensive  odor. 
A  polypus,  when  small,  usually  causes  little  inconvenience,  nor  is 
its  presence  commonly  detected,  except  by  careful  inspection  ; — when 
it  grows  large,  however,  a  sensation  of  fulness  is  felt  in  the  ear,  and 
not  unfrequently  there  is  a  sense  of  heaviness,  giddiness,  and  con- 
fusion in  the  head.  These  latter  symptoms  are  greatly  increased 
when  the  polypus  projects  beyond  the  meatus,  and  happens  to  be 
pressed  upon.  Such  pressure  I  have  known  to  produce  complete 
insensibility.  Sometimes  there  is  also  a  shooting  pain  extending 
from  the  car  to  the  temple.     These  symptoms  of  cerebral  irritation 


112  THE     DISEASES     OF     THE     EAR. 

frequently  cause  great  alarm  to  the  patient  and  his  friends,  and  appear 
to  be  the  result  of  pressure  of  the  polypus  on  the  outer  surface  of  the 
membrana  tympani,  and  chain  of  ossicles,  ^vhich  causes  a  movement 
inwards,  towards  the  cavity  of  the  vestibule,  of  the  inner  extremity 
of  the  chain,  producing  continuous  tension  of  the  fluid  of  the  vesti- 
bule. This  is  clearly  shown  by  careful  inspection  of  a  specimen 
prepared  by  me  for  the  purpose,  by  which  it  is  manifest,  that  although 
there  are  two  articulations  between  the  long  process  of  the  malleus 
and  the  base  of  the  stapes,  yet  the  slightest  movement  inwards  of 
the  processus  longus  mallei  causes  the  base  of  the  stapes  to  be 
pressed  inwards  towards  the  cavity  of  the  vestibule :  and,  as  has 
been  already  stated,  pressure  on  the  contents  of  the  vestibule 
appears  to  produce  results  very  similar  to  those  of  pressure  on  the 
brain.  According  to  my  own  observation,  the  former  gives  rise  to — 
first,  a  sensation  of  noises  ;  secondly,  confusion  of  ideas ;  thirdly, 
giddiness  and  insensibility. 

In  all  cases  of  discharge  from  the  meatus,  the  first  step  is  by  the 
syringe  to  cleanse  the  tube.  This  done,  there  is  no  difficulty  in 
determining  Avhether  a  polypus  be  present,  even  though  it  should  be 
situated  close  to  the  membrana  tympani. 

Polypi  of  the  external  meatus  may  be  divided  into  three  classes. 

1.  The  one  of  most  frequent  occurrence,  and  which  may  be  called 
the  raspberry  cellular  polypus. 

2.  That  Avhich  has  been  termed  the  fibro-gelatinous  polypus. 

3.  The  globular  cellular  polypus. 

Each  of  these  classes,  and  its  treatment,  will  now  be  separately 
described. 

1.  The  Raspberry  Cellular  Polypus. 

I  have  given  this  name  to  the  polypus  most  frequently  met  with, 
which  consists  of  numerous  round  beads,  very  similar  in  appearance 

Fig.  27. 


Raspberry  Cellular  Polypus. 

to  the  free  surface  of  the  raspberry.     These  beads  are  attached  by 
small  filaments  to  a  central  stem,  which  forms  the  root.     Frequently 


THE    EXTERNAL    MEATUS. 


113 


it  is  covered  by   ciliated   epithelium,   and  Avhen   examined  micro- 
scopically, its  interior  is  found  to  be  composed  of  small  rounded 


Fig.  28. 


Cellular  structure  of  the  Raspberry  Polypus. 

cells.  So  soft  is  it  usually,  that  upon  being  seized  by  the  ordinary 
dressing  forceps,  it  breaks  up,  and  bleeds  freely.  This  kind  of 
polypus  varies  much  in  size ;  being  sometimes  not  larger  than  a 
grain  or  two  of  mustard-seed,  and  at  others  so  largo  as  to  fill  the 
whole  of  the  meatus,  and  project  from  the  orifice.  It  is  attached  to 
various  parts  of  the  meatus,  but  generally  to  the  inner  half  of  the 
tube,  and  frequently  close  to  the  membrana  tympani.  When  small, 
its  color  is  usually  deep  red ;  but  as  it  grows,  it  becomes  paler,  and 
the  rounded  masses  considerably  increase  in  size.  The  formation 
of  these  polypi  is  often  attended  with  considerable  pain,  and  by  a 


Fig.  29. 


A  large  Raspberry  Polypus,  visible  at  the  orifice  of  the  Meatus. 


discharge  of  blood ;  but  it  is  not  uncommon  for  them  to  remain  un- 
disturbed for  several  years,  during  the  whole  of  the  time  throwing 
off  a  most  offensive  secretion,  and  yet  not  producing  symptoms  suflS- 

8 


114  THE    DISEASES    OF     THE     EAR. 

cientlj  urgent  to  induce  tlie  patient  to  apply  for  relief;  while  in 
other  cases,  again,  the  head-symptoms  are  so  distressing  as  to  cause 
serious  alarm. 

The  treatment  usually  adopted  consists  either  in  applying  astrin- 
gent lotions  and  drops,  or  in  endeavoring  to  remove  the  mass  hy  in- 
strumental means.  As  to  astringent  applications,  there  can  be  no 
doubt  that  they  are  usually  ineffectual  in  preventing  the  growth  of 
the  polypus,  in  diminishing  its  vascularity,  or  in  abating  the  quan- 
tity of  secretion.  The  same  remark  applies  to  the  use  of  nitrate  of 
silver  ;  for  even  under  the  influence  of  a  strong  solution  of  this  sub- 
stance, or  of  the  solid  nitrate  of  silver  itself,  I  have  seen  the  cellular 
polypus  not  only  retain  its  vascularity,  but  rapidly  increase  in  size. 
The  two  plans  adopted  by  me  ior  the  removal  of  this  kind  of  poly- 
pus, are  the  application  of  the  potassa  cum  calce,  and  the  use  of  the 
lever-ring  forceps. 

1st.  Of  the  use  of  the  jjotassa  cum  calce. — In  the  early  part  of 
1852,  a  series  of  papers  were  published  by  me  in  the  Medical  Times 
and  Gazette^  advocating  the  use  of  the  potassa  cum  calce  ;  but  since 
then  I  have  suggested  the  use  of  the  lever-ring  forceps,  the  employ- 
ment of  which  is  so  satisfactory  that  now  I  seldom  resort  to  the 
former  method.  As,  however,  few  medical  men  are  likely  to  pos- 
sess that  instrument,  and  as  the  use  of  the  potassa  cum  calce  ap- 
pears to  be  the  next  best  plan  for  the  removal  of  this  excrescence, 
it  is  as  well  to  give  the  result  of  my  experience  in  that  respect.  In 
the  first  place,  it  is  of  consequence  that  the  substance  used  should 
be  made  into  very  thin  sticks.  Those  supplied  to  me  by  Mr.  Squire, 
in  the  form  recommended  by  Dr.  H.  Bennet,  answer  the  purpose 
extremely  well  so  long  as  they  retain  their  size  and  form ;  but  as 
this  substance  deliquesces  very  rapidly,  the  greatest  care  should  be 
taken  to  exclude  it  from  the  air.  For  use  at  St.  Mary's  Hospital, 
the  potassa  cum  calce  has  been  manufactured  by  Bailey,  of  Wolver- 
hampton, and  recast  into  smaller  sticks  by  Hopkins  <5c  AVilliams,  of 
New  Cavendish  Street.  This  material  contains  a  small  quantity  of 
iron,  which  makes  its  firmer  and  less  deliquescent  than  that  made  in 
the  usual  way.  The  latter  preparation,  as  not  requiring  so  much 
care,  may  perhaps  suit  those  better  Avho  are  not  often  required  to 
apply  the  remedy  ;  though  that  which  is  free  from  iron  is  decidedly 
the  most  efficacious. 

In  applying  the  potassa  cum  calce,  the  first  step  is  to  syringe  out 
the  ear  with  warm  water,  and  the  next  to  dry  it  with  cotton-wool. 


THE     EXTERNAL    MEATUS.  115 

The  patient  should  then  be  phiced  before  a  strong  light,  so  that  the 
surgeon,  having  a  distinct  view  of  the  polypus,  may  take  a  stick  of 
the  caustic  in  the  right  hand,  while  he  liolds  the  ear  back  with  the 
left ;  but  the  greatest  care  must  be  taken  not  to  touch  the  surface 
of  the  meatus,  which  is  so  extremely  sensitive  that  the  pain  produced 
by  the  action  of  an  escharotic  upon  it  is  most  acute.  For  the  pur- 
pose of  shielding  the  meatus,  an  oval  glass  tube  may  be  used  ;  it  is 
to  be  passed  down  the  meatus  as  far  as  the  polypus,  when,  by 
gentle  pressure,  a  portion  of  the  excrescence  may  be  made  to  enter 
the  distal  end  of  the  tube.  The  polypus,  unlike  the  meatus,  has  but 
little  sensibility,  and  the  potassa  is  to  be  pressed  gently  against  it, 
the  immediate  effect  of  which  is  to  decompose  the  whole  of  the  sub- 
stance to  which  it  extends.  If  a  pair  of  rectangular  forceps  be  em- 
ployed, neither  the  hand  of  the  surgeon,  nor  the  instrument  he  em- 
ploys, will  prevent  the  operator  from  seeing  the  polypus  while  he  is 
making  the  application,  and  he  can  be  sure  that  he  touches  the  Avhole 
of  the  free  surface.  If  this  opei'ation  be  carefully  effected,  the 
patient  scarcely  complains  of  pain  ;  but  if  any  portion  of  the  escha- 
rotic happens  to  reach  the  surface  of  the  tube,  the  acute  pain  it 
causes  can  be  immediately  arrested  by  syringing  the  ear  with  warm 
water,  which  should  always  be  at  hand.  Supposing  the  potassa  to 
have  been  thoroughly  applied,  the  color  of  the  polypus  at  once 
changes  from  a  bright  red  to  a  livid  hue.  After  the  operation,  the 
patient  should  sit  still  for  three  or  four  minutes  ;  and  if  the  glass 
tube  has  been  employed,  it  should  be  allowed  to  remain  fixed  as 
during  the  operation.  Upon  inspecting  the  polypus  after  three  or 
four  minutes,  it  will  be  found  to  be  broken  up,  and  blood  to  be  ooz- 
ing from  it ;  while  instead  of  its  former  rounded  head,  it  presents 
an  uneven  pulpy  mass.  The  meatus  should  next  be  syringed  out 
with  tepid  water,  when  blood  mixed  with  the  debris  of  the  polypus 
in  a  filamentous  form  comes  away.  The  surface  of  the  polypus  still 
retains  its  dark  color,  and,  during  several  hours,  a  process  of  slow 
dissolution  takes  place  in  all  that  part  which  the  escharotic  has 
reached.  If  tlie  cotton-wool  has  rendered  the  polypus  quite  dry,  it 
is  desirable  to  moisten  the  potassa  very  slightly.  As  a  general 
rule,  the  potassa  may  be  again  applied  the  following  day  ;  and  the 
process,  already  described,  repeated,  until  the  Avhole  mass  is  de- 
stroyed. 

Case  I.    Vascular  jJolypi  near  the  memhrana  tympani;  singing  in 
the  car ;  power  of  hearing  diminished;  treated  ivith  potassa  cum 


116  THE    DISEASES    OF    THE    EAR, 

calce;  cure. — Mr.  W.  L.,  aged  40,  was  sent  to  me  on  the  20tli  July, 
1850,  by  Mr.  Cock,  of  Guy's  Hospital.  He  was  a  large,  strong 
man,  and  in  good  health.  He  stated  that  five  or  six  months  ago  he 
found  that  he  was  dull  of  hearing  in  the  left  ear  ;  this  dulness  was 
removed  by  the  use  of  the  syringe,  which  brought  away  a  large 
quantity  of  cerumen.  He  remained  without  cause  of  complaint 
until  three  months  ago,  Avhen  the  symptom  returned  in  the  left  ear. 
He  was  again  in  some  measure  relieved  by  syringing ;  but  this  ope- 
ration was  followed  by  a  discharge  of  very  offensive  character,  at- 
tended by  a  sensation  of  singing  in  the  ear.  He  has  at  times  com- 
plained of  slight  pain  in  the  ear.  On  examination,  the  meatus  was 
found  to  be  full  of  matter,  Avhicli,  after  being  removed,  was  seen  to 
consist  of  adhesive  mucus  mixed  with  epidermoid  cells  ;  the  latter 
giving  a  milky  aspect  to  the  matter.  The  former  presented  nume- 
rous small  flocculi,  or  rather  little  particles  like  cotton  thread,  from 
a  line  and  a  half  to  three  lines  in  length.  On  re-examination  of  the 
meatus,  after  this  mucous  fluid  had  been  withdrawn,  a  red-colored 
polypus  was  seen,  situated  deep  in  the  meatus,  of  which  it  apparently 
occupied  the  inner  fourth,  entirely  obstructing  the  view  of  the  mem- 
brana  tympani.  The  power  of  hearing  was  much  diminished,  a  watch 
not  being  heard  except  when  pressed  upon  the  outer  ear.  From 
the  treatment  of  similar  cases,  I  thought  it  undesirable  to  attempt  a 
removal  of  this  mass  by  instruments,  not  only  on  account  of  the  soft 
nature  of  the  polypus  and  its  extreme  sensitiveness,  but  also  from  the 
uncertainty  as  to  the  part  to  Avhich  the  roots  of  the  polypus  Avere 
attached  ;  I  felt  also  that  if  it  were  fixed  to  tlie  membrana  tympani, 
the  use  of  any  force  might  be  injurious  to  that  organ.  Having  since 
ascertained  by  dissections^  that  the  dermoid  layer  of  the  meatus  is 
continuous  with  the  dermoid  lamina  of  the  membrana  tympani,  it 
appears  desirable  on  this  account  also  not  to  use  any  force  to  a 
polypus  attached  to  the  vicinity  of  the  membrana  tympani,  since  a 
laceration  of  the  meatus  is  likely  to  extend  to  the  membrane. 

July  21st. — The  potassa  cum  calce  was  applied'  to  the  surface  of 
the  polypus  in  the  way  previously  described  ;  and  in  the  course  of 
a  minute  the  whole  of  that  part  of  the  polypus  which  could  be  seen 
became  of  a  livid  hue,  and,  when  tlie  ear  was  syringed  with  tepid 
water  five  minutes  afterwards,  numerous  small  particles  of  the  poly- 
pus, softened  and  disintegrated,  were  brought  away.     The  patient 

'See,   by  the  author,  "On  the  Structure  of  the  Membrana  Tympani  in  the  Human 
Ear."— Philos.  Trans.      Part  I,  1851. 


THE    EXTERNAL    MEATUS.  117 

complained  of  but  very  slight  pain,  -wliicli  entirely  disappeared  on 
using  the  syringe. 

29th. — The  polypus  is  smaller  and  less  red  ;  the  discharge  from 
the  meatus  very  copious.  The  potassa  cum  calce  Avas  again  applied 
with  similar  results. 

August  13th. — The  polypus  is  observed  to  be  much  smaller.  In- 
stead of  the  mass  which,  at  the  first  examination,  had  an  appearance 
like  a  raspberry,  there  was  now  only  a  rounded  button,  about  a  line 
and  a  half  in  diameter.     The  potassa  cum  calce  repeated. 

Oct.  18th. — The  discharge  is  much  diminished  ;  its  odor  is  less 
fetid  ;  polypus  nearly  gone  ;  and  the  power  of  hearing  much  im- 
proved. 

Nov.  13th. — Since  the  last  visit,  a  lotion,  composed  of  a  drachm 
of  tannin  to  eight  ounces  of  water,  has  been  used  twice  daily.  The 
discharge  has  now  nearly  disappeared,  and  consists  almost  entirely 
of  epidermoid  cells.  The  only  vestige  of  the  polypus  consists  in  the 
presence  of  two  very  small  buttons,  each  the  size  of  a  small  pin's 
head  ;  these  are  attached  to  the  upper  part  of  the  membranous  mea- 
tus, close  to  the  membrana  tympani. 

29th. — The  use  of  the  injection  has  been  continued  ;  there  is  now 
no  vestige  of  the  polypus  ;  the  singing  noise  has  ceased ;  but  the 
surface  of  the  membrana  tympani  is  dull.  Hearing  distance  of  the 
watch,  six  inches. 

The  features  of  interest  in  this  case  appear  to  be  :  first,  that  al- 
though the  escharotic  Avas  only  applied  at  intervals  of  several  weeks, 
the  polypus  did  not  increase  in  those  intervals,  but,  on  the  contrary, 
gradually  diminished  ;  secondly,  with  the  destruction  of  the  polypus 
the  singing  also  entirely  disappeared ;  thirdly,  the  return  of  the 
power  of  hearing  to  so  great  an  extent. 

Case  II.  Discharge  from  the  left  ear  during  many  years  ;  giddi- 
ness ;  polypus;  treated  by  jjotassa  cum  calce  ;  cure. — The  Rev.  H. 
C,  aged  40,  consulted  me  on  the  21st  April,  1851.  His  constitu- 
tion was  not  robust,  as  he  had  spent  some  time  in  India.  The  his- 
tory of  his  case  is,  that  the  left  ear  has  been  deaf  from  childliood  : 
that  since  early  life  he  has  been  troubled  with  a  discharge  of  offen- 
sive matter  from  tliat  ear ;  and  that  lately  he  has  complained  of 
attacks  of  giddiness,  especially  upon  suddenly  rising  from  his  chair. 
Upon  examination,  a  red  polypus  was  observed  to  fill  the  inner  half 
of  the  meatus.  The  same  treatment  was  adopted  in  this  case  as  in 
the  last,  with  the  exception  that,  as  the  patient  lived  in  the  country, 


118  THE     DISEASES     OF    THE     EAR. 

he  luul  the  potassa  cum  calce  applied  two  or  three  times  in  the  space 
of  nine  or  ten  days,  and  then  a  larger  interval  elapsed  hefore  it 
was  affain  used.  The  same  result,  however,  ensued  ;  and  at  the 
end  of  six  months  the  pol^-pus  had  disappeared,  and  the  symptoms 
of  friddiness  wholly  vanished. 

In  another  case,  that  of  a  patient  aged  26,  where  the  polypus  filled 
the  whole  of  the  meatus,  portions  were  removed  by  forceps  and  the 
remainder  destroyed  by  potassa  cum  calce.  The  symptom  of  spe- 
cial interest  in  this  case  was  the  production  of  giddiness  by  pressure 
on  the  outer  part  of  the  polypus. 

In  cases  of  polypus  which  coexist  with  catarrhal  inflammation  of 
the  dermoid  meatus,  it  is  desirable  to  keep  a  slight  counter-irritation, 
by  vesicating  paper,  over  the  mastoid  process,  Avhile  the  polypus  is 
being  treated  by  the  potassa  cum  calce.  In  order  to  remove  the 
unpleasant  odor  of  the  discharge,  an  injection,  composed  of  one  part 
of  the  solution  of  chloride  of  lime  to  twelve  parts  of  water,  may  be 
used  three  or  four  times  daily. 

2d.  On  the  removal  of  the  vascvlar  jyoli/pns  hy  the  lever-ring  foreeps. 
— Every  surgeon  who  has  attempted  to  remove  a  polypus,  especially 
when  situated  near  to  the  membrana  tympani,  must  have  found  him- 
self unsuccessful,  if  he  has  used  the  ordinary  forceps.  In  the  first 
place,  it  is  almost  impossible  to  lay  hold  of  the  growth,  on  account  of 
the  small  size  of  the  tube  preventing  him  from  separating  the  blades 
of  the  instrument ;  and  should  a  large  meatus  enable  him  to  do  this, 
the  instrument  blocks  up  so  much  of  the  tube  that  he  cannot  see 
whether  he  lays  hold  of  the  polypus  or  not.  Should  the  surgeon 
even  succeed  in  seizing  the  polypus,  he  will  find  that  it  breaks  up 
and  the  roots  are  not  touched. 

Various  instruments  have  been  invented,  having  for  their  object 
the  removal  of  the  small  vascular  polypi  from  the  external  auditory 
meatus.  Of  these,  one  of  the  best  is  the  snare  of  Mr.  "Wilde,  thus 
described  at  page  420  of  that  gentleman's  work  on  "  Aural  Sur- 
gery :"— 

"  It  consists  of  a  fine  steel  stem,  five  inches  long,  and  bent  in  the 
centre,  with  a  movable  bar  sliding  on  the  square  portion  near  the 
handle,  which  latter  fits  over  the  thumb.  The  upper  extremity  is 
perforated  with  holes  running  parallel  with  the  stem,  and  loops  at 
the  angle  serve  the  same  purpose.  A  fine  wire,  fastened  to  the 
cross-bar,  passes  through  these  loops  and  holes;  it  should  be  of  such 
length,  that  when  the  cross-bar  is  drawn  up  tight  to  the  handle,  the 


THE     EXTERNAL     MEATUS. 


119 


ligature  is  fully  on  the  stretch.   ...  In  using  it,  the  cross-bar  is 
pushed  forward,  and  a  noose  made  of  the  wire  at  the  small  extre- 


FiG.  30. 


mity,  of  sufficient  size  to  include  the  morbid  growth,  which  it  is  then 
made  to  surround,  and  towards  the  roots  of  which  it  is  pressed  by 
means  of  the  stem ;  the  cross-bar  is  then  drawn  up  smartly  to  the 
handle,  while  the  point  of  the  stem  is  pressed  downwards ;  and  it 
never  fails  of  either  cutting  across,  or  of  drawing  with  it  whatever 
was  included  in  the  noose." 

The  difficulty  attendant  upon  the  use  of  this  instrument,  consists 
in  getting  the  wire  noose  around  the  polypus,  which  frequently  is  of 
very  small  size  ;  another  disadvantage  is,  that  it  cuts  off  a  portion 
of  the  growth,  instead  of  withdrawing  it  entire. 

The  instrument  which  I  have  been  in  the  habit  of  using  during 
several  years  at  St.  Mary's  Hospital,  as  well  as  in  private  practice, 
with  most  satisfactory  results,  I  have  called  the  lever-ring  forceps. 
In  the  interior  of  a  tube  is  a  delicate  steel  rod,  the  end  of  which  is 
split  into  two  portions,  each  having  a  small  oval  ring  at  its  extre- 
mity, measuring  four  or  five  lines  long,  and  from  tAvo  to  three  broad. 
These  rings  (the  inner  surfaces  of  which  are  slightly  serrated)  are 
separated  from  each  other  when  the  lever  is  not  pressed ;  but  as  soon 
as  it  is  pressed,  the  rings  are  brought  into  contact.     The  instrument 

Fig.  31. 


The  Lever-ring  Forceps,  open. 


is  introduced  into  the  meatus  with  the  rings  apart,  which  having 
been  made  to  inclose  the  polypus,  or  a  portion  of  it,  between  them, 
the  lever  is  pressed  down,  the  polypus  seized,  and  instantly  drawn 
out. 


120  THE     DISEASES    OF    THE    EAR. 

Case  III.  A  cellular  raspbc7-ri/  j^olypus  in  each  ear  removed  hy  the 
lever-ring  forceps;  great  improvement. — M.  I.,  aged  20,  in  good 
health,  but  having  a  tendency  to  glandular  enlargements,  consulted 
me  on  March  7th,  1853. 

History. — "When  a  child,  suffered  on  several  occasions  from  attacks 
of  deafness,  Avhich  lasted  from  ten  days  to  three  or  four  months,  but 
by  degrees  disappeared.  Between  three  and  four  years  ago,  the 
left  ear  began  to  discharge,  and  has  ocntinued  to  do  so  up  to  the 
present  time.  Within  the  last  two  months,  the  power  of  hearing  in 
the  left  ear  has  so  much  decreased  that  he  requires  to  be  loudly 
spoken  to  close  to  it.  A  month  ago,  the  right  ear  began  to  discharge, 
and  is  nearly  as  deaf  as  the  left. 

On  examination,  the  Avatch  was  heard  by  the  left  ear  when  pressed 
against  it ;  by  the  right  when  in  contact.  In  each  ear,  near  to  the 
membrana  tympani,  was  a  large  vascular  polypus.  When  an  attempt 
at  a  forcible  expiration  was  made  with  closed  nostrils,  air  passed 
freely  out  of  the  left  meatus,  but  not  through  the  right.  The  mucous 
membrane  of  the  fauces  was  thick  and  red. 

Previous  treatment. — Excision  of  the  tonsils,  and  the  introduction 
of  cotton-wool  into  the  bottom  of  the  meatus.  Neither  operation  was 
productive  of  benefit. 

Treatment. — The  polypus,  by  means  of  the  lever-ring  forceps,  was 
first  removed  from  the  right  ear.  The  patient  stood  upright,  and 
reclined  the  head  slightly  towards  the  left  shoulder.  The  gas  lamp 
being  held  between  the  teeth,  the  patient's  car  was  drawn  backwards 
by  the  left  hand,  so  as  to  dilate  and  straighten  the  meatus  as  much 
as  possible  ;  a  large-sized  speculum  was  next  introduced ;  and  then, 
with  the  right  hand,  the  lever-ring  forceps  was  gradually  pushed 
down  to  the  polypus  with  the  rings  in  contact.  As  soon  as  the  rings 
reached  the  polypus  they  were  allowed  to  separate,  and  when  thus 
apart  were  made  to  surround  the  growth ;  when  this  was  effected, 
the  rings  were  brought  into  contact  by  pressing  on  the  lever.  The 
instrument  Avas  then  AvithdraAvn,  bringing  with  it  the  polypus,  and 
leaving  the  membrana  tympani  exposed.  During  the  whole  of  the 
operation  I  Avas  able  to  see  Avhat  I  Avas  doing,  the  rod  of  the  instru- 
ment being  so  small  as  to  occupy  only  a  trifling  portion  of  the  tube. 
On  the  folloAving  day  the  hearing  of  the  patient  Avas  much  improved, 
the  Avatcli  being  heard  at  a  distance  of  tAvo  inches ;  and  the  quantity 
of  discharge  had  greatly  diminished.  The  polypus  in  the  left  meatus 
Avas  noAv  attacked ;  but  as  only  small  portions  of  it  came  aAvay  at  a 


THE    EXTERNAL    MEATUS.  121 

time,  three  or  four  operations  were  required,  wliicli  were  followed  by 
mueli  improvement.    A  large  aperture  was  detected  in  the  membrana 


Fig.  32. 


The  Lever-ring  Forceps  holding  a  Polypus. 

tympani,  and,  by  the  aid  of  the  artificial  membrane,  the  hearing 
power  was  still  further  improved. 

Case  IV.  Obstruction  of  the  Eustachian  tiihe  atthefaucial  orifice; 
cellular  i^olypus  in  the  external  meatus;  removal;  cure. — H.  W., 
Esq.,  aged  19,  pupil  to  an  architect,  consulted  me  on  February 
19th,  1854,  on  account  of  deafness  in  both  ears,  and  discharge  from 
the  right. 

History. — From  childhood  has  been  subject  to  attacks  of  deafness 
during  a  cold ;  but  they  have  disappeared  after  a  duration  of  three 
or  four  weeks.  About  two  years  ago,  he  had  an  attack  of  deafness, 
which  was  folloAved  by  discharge  from  the  right  ear  ;  this  has  lately 
increased,  while  the  hearing  power  has  considerably  diminished.  At 
the  present  time  he  has  to  be  spoken  to  in  a  loud  voice  within  the 
distance  of  a  yard.  On  examination,  the  watch  was  heard  only 
when  in  contact  with  the  right  ear.  There  was  a  large  quantity  of 
mucous  discharge  in  the  meatus,  on  removing  which,  a  red  polypus, 
with  numerous  projections  from  its  surface,  Avas  seen  to  occupy  the 
inner  half  of  the  tube.  The  Eustachian  tube  was  impervious.  Left 
ear — hearing  distance  six  inches  ;  membrana  tympani  opaque  and 
partly  calcareous  ;  the  Eustachian  tube  impervious  ;  and  the  mucous 
membrane  of  the  fauces  red  and  thick. 

Treatment. — On  the  25th  February,  by  means  of  the  lever-ring 
forceps,  I  removed  a  polypus  as  large  as  a  horse-bean,  which  was 
attached  to  the  posterior  surface  of  the  meatus,  close  to  the  mem- 
brana   tympani.      On    the    1st    March,    the    discharge    had  nearly 


122  THE    DISEASES     OF    THE    EAR. 

vanished  ;  and  the  membrana  tympani  vas  seen  to  be  entire,  though 
calcareous  at  parts.  The  hearing  was  much  improved  ;  the  ■\vatch 
being  heard  at  the  distance  of  two  inches.  Tonic  medicines  were 
administered  ;  the  surface  of  the  body  to  be  sponged  Avith  vinegar 
and  water  ;  and  an  acid  astringent  gargle  to  be  used  thrice  daily. 

March  8th.  Hears  much  better.  Two  days  before,  after  garg- 
ling, a  sudden  crack  was  felt  in  the  right  ear,  after  which  he  heard 
most  acutely.  Does  not  hear  quite  so  well  to-day,  but  still  hears 
general  conversation. 

April  3d. — The  left  ear  has  also  much  improved :  can  now  hear 
perfectly. 

March,  1855. — Have  seen  this  patient  recently,  and  he  has  re- 
mained quite  well. 

CaseY.  Cellular  poll/pus,  causing  deafness  and  serious  cerebral 
symptoms;  removal;  cure. — I.  E.,  Esq.,  aged  21,  was  sent  tome 
by  Dr.  Conolly  on  the  10th  February,  1855,  on  account  of  deafness 
in  the  left  ear,  accompanied  by  occasional  giddiness. 

History. — Since  six  years  of  age  has  been  subject  to  an  offensive 
discharge  from  the  left  ear,  with  an  occasional  flow  of  blood :  has 
not  experienced  pain,  but  has  frequently  had  a  sensation  of  fulness 
in  the  ear  ;  and  Avhen  the  ear  has  been  pressed  upon,  there  has  been 
considerable  giddiness.  Recently,  symptoms  of  unnatural  mental 
excitement  have  been  experienced.  On  examination,  it  was  found 
that  the  watch  could  not  be  heard,  though  the  crack  of  the  nails 
was  distinguishable.  On  looking  into  the  ear,  a  polypus  was  seen 
within  half  an  inch  of  the  orifice  of  the  meatus,  deep  red  in  color, 
and  covered  by  a  transparent  discharge.  Pressure  at  once  produced 
a  sensation  of  giddiness. 

Treatment. — The  polypus  being  of  a  large  size,  and  somewhat 
firm,  it  was  resolved  to  attempt  its  removal  by  the  ring  forceps ;  a 
considerable  portion  of  the  mass  was  thus  extracted  but  the  roots 
remained.  Great  relief  at  once  followed  the  operation  ;  and  ulti- 
mately the  lever-ring  forceps  succeeded  in  removing  the  rest  of  the 
morbid  growth.  The  membrana  tympani  was  found  to  be  entire  ; 
the  hearing  was  greatly  improved,  and  the  head-symptoms  wholly 
disappeared. 


THE     EXTERNAL     MEATUS.  123 


2.  The  Fibho-Gelatinous  Polypus. 

Next  in  frequency  of  occurrence  to  the  vascular  is  the  one  termed 
the  gehitinous  polypus.  This  name  has  been  given  to  it  from  the 
soft  jelly-like  appearance  of  its  free  portions,  and  from  the  similarity 
of  its  general  aspect  to  the  gelatinous  nasal  polypus.  Careful  and 
minute  examination,  aided  by  the  microscope,  docs  not,  however, 
confirm  the  propriety  of  the  designation,  for,  as  will  be  seen  pre- 
sently, the  term  '■'■fibro-gelatlnous  polypus"  would  be  the  more  ap- 
propriate appellation. 

Structure  of  gelatinous  jjolt/pus. — This  morbid  growth  generally 
attains  to  a  large  size.  There  are  in  my  museum  specimens  vary- 
ing from  the  size  of  the  last  joint  of  the  thumb  to  that  of  a  small 
bean.  Sometimes  this  polypus  has  a  single  root  and  body,  but  more 
usually  two  or  more  bodies  have  a  common  base.  The  root,  which 
is  attached  to  the  wall  of  the  meatus,  is  generally  not  larger  than  a 
line  or  two  lines  in  diameter.  Examining  the  polypus  as  it  ap- 
proaches the  orifice  of  the  meatus,  near  the  root  will  be  found  at- 
tached numerous  small  rounded  growths  very  like  delicate  granula- 
tions, which  appear  to  be  the  rudimentary  growths  prevented  from 
developing  by  the  pressure  exerted  upon  them  by  the  Avails  of  the 
meatus  and  the  larger  expanded  part  of  the  outer  portions  of  the 

Fig.  33. 


Fibro-gelatinous  Polypus  ;   the  pedicle  is  to  the  right,  the  two  rounded  masses 
projected  from  the  orifice  of  the  meatus. 

growth.  Approaching  the  orifice  of  the  meatus  the  polypus  assumes 
a  globular  form,  consisting  of  from  one  to  as  many  as  six  or  eight 
rounded  heads.  When. these  heads  are  numerous,  they  have  pedicles, 
varying  in  length  from  a  quarter  to  half  an  inch,  and  connecting 
them  with  the  root.  The  surface  of  this  polypus  is  smooth,  and  is 
constituted  of  a  layer  of  about  a  quarter  of  a  line  thick,  which  may 


124  TUE    DISEASES    OF    THE     EAR. 

be  separated  from  it  l)y  maceration,  and  Avliicli  consists  of  cells  bear- 
ing every  resemblance  to  those  of  the  epithelium  covering  the  buccal 
mucous  membrane.  This  epithelial  layer  is  as  thick  and  Avhite  as 
ordinary  writing-paper  ;  and  ■when  detached  and  floating  about,  it 
retains  the  shape  of  the  polypus  of  •which  it  had  formed  the  surface. 
The  interior  of  the  gelatinous  polypus  is  composed  of  corpuscles  and 
fibrous  tissue,  varying  in  proportion  in  different  specimens  ;  but  the 
fibrous  tissue  generally  predominates.  The  corpuscles  have  a  rounded 
form,  but  vary  in  size  and  shape.  In  a  specimen  ■which  Avas  a  fair 
example  of  this  kind  of  polypus  as  it  comes  under  the  notice  of  the 
surgeon  (it  being  Avhite  and  soft,  and  readily  compressible  by  the 
thumb  and  finger),  I  found  these  cells  varied  in  shape  from  a  perfect 
round  to  an  irregular  oval, — and  in  size,  from  that  of  a  blood-cor- 
puscle to  a  half  or  one  (juarter  of  its  dimensions,  the  greater  number 
appearing  certainly  smaller  than  the  blood-disc  ;  but  they  presented 
every  variety  of  size  between  that  disc  and  a  fine  granule  ;  and  there 
■was  very  little  symmetry  in  form  or  size  even  between  those  which 
were  nearest  to  each  other.  These  cells  are  not  generally  in  close 
contact,  but  are  separated  by  a  delicate  gelatinous  substance,  which 
is  sometimes  quite  transparent  and  structureless,  and  occasionally  so 
abundant  as  to  form  by  far  the  largest  portion  of  the  mass.  In  parts 
where  the  polypus  is  resisting,  these  cells  are  separated  by  delicate 
wavy  bands,  having  the  appearance  of  fibres ;  and  to  the  surface  of 
these  fibres  the  cells  arc  observed  to  adhere.  In  some  parts  these 
■wavy  gelatinous-looking  fibres  form  almost  the  entire  substance  of 
the  polypus,  the  rounded  cells  being  scattered  very  sparingly  ;  in 
others  these  fibres  are  absent.  The  wav}^  fibres  run  in  the  long  dia- 
meter of  the  polypus,  possess  considerable  toughness,  and  although 

Fio.  34. 


Structure  of  the  Fibro-gelatinou?  Polypus. 

easily  separated  from  each  other  and  isolated,  they  cannot  be  torn 
across  without  considerable  force.  In  some  instances  these  fibres 
are  extremely  firm,  and  the  polypus  is  entirely  composed  of  them, 


THE     EXTERNAL     MEATUS.  125 

SO  as  to  become  solid  and  very  hard.  When  separated  from  each 
other,  they  wear  the  appearance  of  transparent  lines,  whose  diameter 
varies  from  half  to  a  ({uarter  of  that  of  the  blood-disc.  Interspersed 
through  the  substance  of  the  polypus  Averc  many  spindle-shaped 
crystals.  On  the  application  of  acetic  acid,  the  fibres  became 
swollen,  and  assumed  a  confused  gelatinous  appearance,  losing  all 
their  fibrous  character  ;  the  corpuscles  were  also  converted  into  a 
similar  mass,  in  which,  however,  a  large  number  of  granules  were 
observable.  The  action  of  the  acetic  acid  also  brought  into  view 
a  large  addition  to  the  number  of  fine  spindle-shaped  crystals  pre- 
viously seen.  The  gelatinous  polypus  sometimes  attains  to  so  great 
a  degree  of  hardness  that  it  is  Avith  difficulty  cut  through  by  a  pair 
of  scissors ;  a  condition  Avhich  appears  to  be  produced  by  the  in- 
crease in  quantity  and  solidity  of  the  fibrous  tissue,  the  diminution 
of  the  quantity  of  corpuscles,  and  the  absence  of  the  gelatinous 
matter  betAveen  them.  It  has  been  already  stated  that  the  Avascular 
polypus  is  composed  of  rounded  cells  ;  which,  however,  differ  very 
much  from  the  cells  of  the  gelatinous  polypus,  in  being  all  of  nearly 
the  same  size  and  shape,  and  larger  than  those  previously  described. 
The  cells  of  this  polypus  do  not  appear  to  be  separated  by  any 
substance,  but  they  are  agglomerated  together  and  form  the  entire 
mass  of  the  polypus.  Its  exterior  also  is  smoother  than  that  of  the 
gelatinous  kind,  is  always  covered  by  its  secretion,  and  is  composed 
of  a  layer  of  epithelial  cells  Avhich  frequently  terminate  in  ciliae,  that 
often  continue  in  active  motion  for  a  long  time  after  the  removal  of 
the  portion  of  polypus  AA-hich  they  cover. 

Treatment  of  the  gelatinous  polypus. — The  diiference  in  the  struc- 
ture of  the  three  kinds  of  aural  polypi,  naturally  prepares  the  sur- 
geon for  a  difierence  in  their  treatment.  This  is  undoubtedly  neces- 
sary. The  use  of  the  potassa  cum  calce,  which  has  proved  so  effica- 
cious in  the  destruction  of  the  vascular  polypus,  is  of  but  little 
service  in  the  treatment  of  the  gelatinous,  or,  more  properly  speak- 
ing, the  fibro-gelatinous  polypus.  The  escharotic  produces  so  trifling 
an  effect  upon  fibrous  tissue,  that  removal  by  extraction  must  always 
be  resorted  to.  For  this  purpose,  the  best  instrument  is  a  pair  of 
ring  forceps,  the  ends  of  Avhich  should  be  reduced  in  size  so  as  not 
to  be  larger  than  from  two  to  three  lines  in  diameter.  These  for- 
ceps should  be  introduced  into  the  meatus  to  the  distance  of  half  or 
three-quarters  of  an  inch,  and  the  polypus  seized  as  near  as  possible 
to  its  roots ;  the  forceps  should  then  be  used  as  a  lever,  the  outer 


126  THE    DISEASES     OF    THE     EAR. 

part  of  the  car  being  tlie  fulcrum,  and  the  polypus  turned  out  of  the 
cavity.  But  little  force  is  required ;  and,  as  a  general  rule,  the 
diseased  growth  is  extracted  without  difficulty  in  an   entire  state. 

Fig.  35. 


The  Ring  Forceps. 

In  one  case,  that  of  the  wife  of  a  medical  man,  a  large  gelatinous 
polypus,  which  filled  the  greater  part  of  the  meatus,  was  removed 
by  the  frequent  use  of  the  syringe  and  Avarm  water.  The  traction 
produced  by  the  water  in  making  its  way  outwards,  seemed  in  the 
first  place  to  diminish  the  supply  of  blood  to  the  growth,  which  gra- 
dually darkened  in  color,  and  was  ultimately  expelled.  On  exam- 
ining the  meatus  after  the  removal  of  the  polypus,  the  surface  to 
which  it  was  attached  is  distinctly  discernible,  and,  for  a  short  time, 
there  is  a  slight  oozing  of  blood  from  it.  In  some  cases,  portions 
of  the  root  of  the  polypus  remain ;  they  do  not,  however,  generally 
require  any  further  treatment,  but  gradually  wither  and  disappear. 
If,  on  the  other  hand,  any  of  the  small  globular  bodies  remain  at- 
tached to  the  root,  they  rapidly  increase,  and  the  diseased  growth 
has  again  to  be  submitted  to  operation.  The  removal  of  the  fibro- 
gelatinous  polypus  is  generally  productive  of  relief,  not  only  to  the 
unpleasant  head-symptoms  caused  by  its  pressure  on  the  contents  of 
tlie  vestibule,  but  to  the  diminished  power  of  hearing.  The  latter 
improvement  does  not,  as  might  be  supposed,  take  place  at  once ; 
on  the  contrary,  it  is  not  unusual  for  there  to  be  at  first  no  increase 
of  hearing  power,  though  it  gradually  and  very  slowly  improves. 
This  may,  perhaps,  be  accounted  for  by  the  circumstance,  that  the 
polypus  has  for  a  long  period  exerted  considerable  pressure  upon 
the  membrana  tympani,  or,  where  that  structure  no  longer  exists, 
upon  the  tympanic  ossicles;  which  organs  only  slowly  return  to  their 
natural  state. 

Case  Yl.   Crelatinoiis  j)olypus  in  the  left  ear  for  sei^en  years — in 
the  right  ear  for  one  year  ;  noises  in  the  right  ear;  giddiness  upon 


THE    EXTERNAL    MEATUS.  127 

pressure  of  the  polypus.  Cure  hy  extraction,  folloived  hy  the  appli- 
cation of  alum  and  chloride  of  zinc. — Harriet  Wenlock,  aged  58,  a 
washerwoman,  strong,  rather  stout,  and  in  good  health,  Avith  the  ex- 
ception of  the  symptoms  produced  by  the  polypus,  consulted  me  in 
the  beginning  of  April,  1850.  She  stated  that  seven  years  pre- 
viously, without  any  other  symptoms,  a  discharge  issued  from  the 
left  ear,  which  has  never  disappeared  ;  and  shortly  after  the  appear- 
ance of  the  discharge,  a  rounded  body  Avas  visible  at  the  orifice  of 
the  ear.  About  a  year  ago,  the  right  ear  also  began  to  discharge, 
and  there  soon  appeared  a  swelling  at  the  outer  orifice.  She  com- 
plains of  great  noises  in  the  right  ear  ;  these  vary  much  :  sometimes 
they  appear  like  a  humming,  at  others  like  the  tinkling  of  a  bell, — 
then  as  if  it  were  loudly  ringing.  When  the  surface  of  the  tumor 
in  the  left  ear  is  pressed  upon,  she  feels  giddy,  and  if  it  is  continued, 
loses  her  consciousness,  and  falls.  At  present,  and  for  a  long  time, 
she  has  been  so  hard  of  hearing,  that  she  requires  to  be  loudly  ad- 
dressed close  to  the  head.  On  examination  of  the  right  ear,  a 
round,  pale-colored  polypus,  more  than  half  an  inch  in  diameter, 
was  seen  protruding  from  the  orifice  of  the  meatus,  beloAV  which 
Avas  another  groAvth  about  half  the  size.  At  the  external  meatus  of 
the  left  ear  a  rounded  body  Avas  observable,  of  not  more  than  a  line 
in  diameter,  and  not  extending  beyond  the  orifice.  Not  finding  any 
symptoms  which  indicated  an  affection  of  the  bone,  I  thought  it  best 
at  once  to  remove  the  polypi,  and  selected  the  right  ear  to  begin 
upon.  The  diseased  groAvth  Avas  remoA'ed  with  the  greatest  ease  by 
the  use  of  the  ring  dressing  forceps  in  the  manner  before  described ; 
the  patient  suffered  only  a  slight  and  momentary  pain,  and  there 
Avas  a  very  trifling  oozing  of  blood.  On  examining  it  after  removal, 
the  polypus  Avas  found  to  consist  of  the  tAvo  rounded  heads  already 
noticed,  each  having  a  second  mass,  about  half  the  size,  continuous 
Avith  it,  and  extending  nearly  as  far  as  the  root,  Avhich  was  A'ery 
narroAv,  not  being  more  than  a  line  or  a  line  and  a  half  in  diameter. 
The  surface  of  the  expanded  part  of  this  polypus  was  found  to  be 
covered  Avith  flat  scabs,  like  those  of  epidermis ;  but  nearer  to  the 
root,  elongated  cells,  armed  with  ciliae,  Avere  also  distinguishable. 
The  rounded  parts,  Avhich  were  exposed  to  the  air,  AA'ere  smoother 
and  Avhiter  than  those  which  were  concealed  ;  the  latter  presenting 
a  somewhat  rugous  surface.  On  April  22,  a  fortnight  after,  exa- 
mination shoAved  the  quantity  of  the  discharge  to  be  greater  than 
usual,  and  a  rounded  growth  Avas  perceived  near  to  the  membrana 


128  THE    DISEASES    OF    THE     EAR. 

tjnipani,  as  if  the  roots  of  the  polypus  still  remained  ;  to  this  sub- 
stance a  solution  composed  of  half  a  drachm  of  alum  to  two  ounces 
of  Avatcr  Avas  directed  to  be  applied  thrice  daily.  The  polypus  Avas 
removed  from  the  left  ear,  and  found  to  consist  of  a  pedicle,  a  body, 
and  three  rounded  heads,  tAvo  of  Avliich  had  been  visible  at  the  orifice 
of  the  meatus  during  life. 

April  20. — The  poAver  of  hearing  is  improved.  Has  had  slight 
pain  in  each  ear,  also  some  giddiness.  The  discharge,  though  less 
abundant,  is  still  of  an  offensive  odor.  In  the  right  ear  the  rem- 
nant of  the  polypus  is  seen  attached  to  the  upper  part  of  the  meatus 
near  to  the  membrana  tympani :  in  the  posterior  part  of  the  latter 
an  orifice  Avas  observed.  In  the  left  ear  the  roots  of  the  polypus 
appeared  to  fill  as  much  as  one-half  of  the  meatus.  The  drops  of 
the  solution  of  alum  to  be  continued. 

May  6. — Iliglit  ecw. — The  discharge  has  ceased,  the  hearing  has 
improved,  and  is  much  better  after  bloAving  the  nose.  The  polypus 
has  entirely  disappeared,  and  the  mucous  membrane  of  the  tym- 
panum, Avliich  is  thick  and  red,  is  seen  through  the  orifice  of  the 
membrana  tympani. 

Left  ear. — The  roots  of  the  polypus  are  much  in  the  same  state. 

May  13. — The  roots  of  the  polypus  remain  as  a  Aveek  ago.  Ap- 
plied the  chloride  of  zinc  to  their  surface. 

May  27. — Polypus  of  left  ear  smaller  ;  again  applied  chloride  of 
zinc. 

June  24. — Discharge  from  left  ear  gone.  The  polypus  much  di- 
minished in  size.  Air  passes  through  the  left  membrana  tympani. 
The  solution  of  alum  Avas  continued,  and  in  a  fortnight  the  polypus 
had  Avholly  A'anished. 

Case  VII.  Gelatinous  polyims  cured  hij  extraction;  hearing  poiver 
improved. — J.  W.,  Es(|.,  aged  24,  a  medical  student,  pale  and  not 
strong,  consulted  me  on  the  24th  Octolier,  1851,  on  account  of  so 
great  a  degree  of  hardness  of  hearing,  that  he  Avas  obliged  to  be 
spoken  to  at  a  distance  not  further  than  a  foot  from  his  head.  He 
had  also  an  abundant  discharge  from  the  left  ear.  The  Itistori/  of 
the  case  Avas,  that  tAvelve  years  ago  he  had  an  attack  of  porrigo,  for 
Avhich  the  head  Avas  shaved.  During  this  attack  he  AAas  very  deaf 
in  both  cars,  but  quite  recovered.  A  year  ago,  he  became  sloAvly 
dull  of  hearing  in  the  right  ear  ;  and  for  eight  months  the  left  ear 
has  been  gradually  losing  its  poAver  of  hearing.  Has  had  pain  in 
the  left  car  lately,  Avith  a  discharge,  Avhicli  varies  much  in  quantity. 


THE    EXTERNAL     MEATUS.  129 

and  has  a  very  offensive  odor.  On  examination,  the  hearing  power 
of  the  right  ear,  tested  by  the  watc]!,  was  only  half  an  inch  ;  the 
surface  of  the  membrana  tympani,  was  dull,  and  its  substance 
opaque. 

Left  ear. — Watch  only  heard  when  pressed  upon  the  ear.  A 
polypus  filled  the  meatus  and  extended  as  far  as  the  outer  orifice  : 
it  was  removed  by  the  forceps,  and  the  power  of  hearing  sloAvly 
improved. 

Case  VIII.  G-elatinous  jyolijpus  removed  hy  forceps,  and  potassa 
cum  calce  applied  to  the  roots;  cure. — Miss  E.  II.,  aged  26,  con- 
sulted me  on  April  4,  1851,  on  account  of  a  discharge  from  the 
right  ear.  The  lustory  of  the  case,  as  detailed  to  me,  was,  that  at 
the  age  of  sixteen,  she  had  an  attack  of  scarlet  fever,  with  pain  in 
both  ears,  especially  in  the  right.  The  pain  in  the  right  ear  was 
followed  by  a  discharge,  which  has  continued  to  the  present  time, 
with  the  exception  of  its  once  disappearing  for  a  fortnight,  when 
the  pain  greatly  increased.  On  examination,  a  leaden-hued  polypus 
was  seen  projecting  from  the  orifice  of  the  meatus,  which  was  stated 
to  have  been  seen  there  during  the  four  months  preceding  the  appli- 
cation for  advice  :  pressure  upon  it  had  always  produced  giddiness. 
This  polypus  was  found  to  be  attached  to  the  posterior  and  inferior 
part  of  the  meatus,  close  to  the  membrana  tympani.  It  was  removed 
by  the  dressing  forceps ;  and  as  the  roots  had  a  tendency  to  increase 
in  size,  the  potassa  cum  calce  was  applied  once,  and  the  growth  was 
effectually  destroyed. 

Case  IX.  Gelatinous  polypus  folloiving  bathing;  removed  by  ope- 
ration; cure. — J.  D.,  Esq.,  aged  36,  consulted  me  on  May  20, 
1853,  on  account  of  deafness  in  the  right  ear,  Avith  discharge. 
History. — Five  years  ago,  after  bathing  in  the  sea,  had  pahi  in  the 
left  ear,  followed  by  a  discharge,  that  has  continued  ever  since,  and 
at  times  been  very  offensive.  For  the  last  two  or  three  months  this 
ear  has  become  so  deaf  that  he  can  scarcely  hear  at  all  Avith  it.  On 
examination.,  a  large  gelatinous  polypus  Avas  found  occupying  the 
meatus  nearly  as  far  as  the  orifice.  It  Avas  taken  out  by  the  ring 
forceps,  and  the  hearing  Avas  immediately  improved.  An  orifice 
Avas  detected  in  the  posterior  part  of  the  membrana  tympani.  The 
patient's  hearing  continued  to  improve  ;  the  Avatch  Avas  heard  at  a 
foot  from  the  ear  ;  and  the  discharge  Avholly  disappeared.  The 
roots  of  the  polypus  Avere  found  to  have  been  attached  to  the  sur- 
face of  the  meatus  in  the  vicinity  of  the  membrana  tympani. 

9 


130  the   diseases   of   the   ear. 

3.  The  Globular  Cellular  Polypus. 

The  third  kind  of  polypus  developed  in  the  external  meatus  is  the 
globular  cellular  species.  I  have  thus  named  a  growth  which  essen- 
tially differs  from  those  belonging  to  the  preceding  classes.  It  consists 
of  a  single  globular  mass,  perfectly  smooth  on  the  surface,  and  with- 

FiG.  36. 


Globular  Cellular  Polypus. 

out  any  appearance  of  granulation.  It  is  confined  to  the  inner  fourth 
or  sixth  of  the  meatus,  from  the  upper  part  of  which  it  is  usually  de- 
veloped, and  it  hangs  down  like  a  curtain,  wholly  or  partially  con- 
cealing the  mcmbrana  tympani.  It  is  of  a  deep  red  color,  is  softer 
than  the  ordinary  cellular  polypus,  and  does  not  generally  attain 
a  size  larger  than  a  small  pea.  This  growth  usually  occurs  in  chil- 
dren or  in  young  persons  ;  it  is  attended  by  a  mucous  discharge, 
which  is  often  very  offensive  ;  and  the  secretion,  like  that  from  other 
forms  of  polypus,  consists  of  epidermoid  cells,  which  give  a  milky 
appearance  to  the  water  after  syringing  : — it  also  contains  fine 
threads  of  mucus.  This  kind  of  polypus  may  exist  for  several 
years  without  producing  any  severe  symptoms  ;  and  it  has  not 
hitherto  been  distinguished  from  the  other  varieties  of  polypus.  It 
may  be  discriminated  from  the  disease  I  have  called  chronic  catar- 
rhal inflammation  of  the  dermoid  meatus,  by  the  discharge  contain- 
ing flocculi  of  mucus,  like  small  particles  of  thread,  and  from  its 
always  presenting  a  red  mass  at  the  inner  extremity  of  the  meatus. 
This  affection  also  differs  from  catarrlial  inflammation  of  the  meatus, 
in  never  terminating  in  disease  of  the  bone  ;  the  discharge  appear- 
ing to  proceed  from  and  be  confined  to  the  surface  of  the  polypus 
only.  The  aural  disease  with  which  the  globular  cellular  polypus 
is  most  likely  to  be  confounded,  is  catarrhal  inflammation  of  the 
mucous  membrane  of  the  tympanum  :  since,  in  some  cases  of  the 
latter,  the  mucous  membrane  is  of  a  deep  red  color,  and  so  much 
tumefied  that  it  projects  into  the  meatus  for  a  line  or  a  line  and  a  half 
beyond  the  position  occupied  by  the  membrana  tympani  previous  to 


THE    EXTERNAL    MEATUS.  131 

its  destruction.  On  examining  the  growth  by  means  of  the  specu- 
lum and  lamp,  it  is  not  always  easy  to  determine  which  of  the  two 
diseases  just  described  is  present.  The  examination  of  the  dis- 
charge, however,  is  suflScient  to  decide  the  question  ;  for,  although 
in  both  aflFections  floccular  mucus  is  present,  that  accompanying  the 
polypus  is  composed  of  small  thread-like  particles,  while  that  emana- 
ting from  the  mucous  membrane  of  the  tympanum  presents  large 
irregidar-shapcd  masses,  generally  of  a  yellow  color.  The  history 
of  the  case  will  also  usually  aid  the  surgeon  in  forming  a  diagnosis, 
as  the  globular  cellular  polypus  ordinarily  appears  without  the  mani- 
festation of  any  very  decided  symptom  ;  perhaps  the  appearance  of 
the  discharrre  is  the  first  indication  of  its  existence  :  whereas  the 
affection  of  the  tympanum  generally  originates  in  an  attack  of  acute 
inflammation,  and  often  arises  during  scarlet  fever  or  measles. 

Treatment. — The  treatment  of  this  kind  of  polypus  is  much  more 
simple  than  that  of  the  two  species  first  described  ;  nevertheless, 
except  the  true  nature  of  the  disease  be  ascertained,  it  is  useless  to 
employ  the  astringent  applications  commonly  prescribed  to  arrest 
discharjres  from  the  ears.  This  affection  stands  between  the  ordi- 
nary  vascular  polypus  and  catarrhal  inflammation  of  the  dermoid 
meatus  ;  the  former  being  wholly  uninfluenced  by  the  use  of  the 
strongest  astringents,  and  the  latter  being  generally  curable  by 
weak  solutions  of  them :  while  the  globular  cellular  polypus,  though 
affected  by  astringent  applications,  requires  them  to  be  of  conside- 
rable strength.  The  course  of  treatment  followed  by  me,  consists 
in  syringing  out  the  meatus  of  the  affected  ear  with  tepid  water,  to 
remove  all  discharge  ;  and  after  the  ear  has  been  turned  towards 
the  shoulder  of  the  side  affected,  to  alloAV  of  the  water  running  out, 
then  to  let  three  or  four  drops  of  an  astringent  solution  fall  into  the 
meatus,  and  close  the  ear  for  half  an  hour  by  a  portion  of  cotton- 
wool, moistened  with  the  solution.  This  course  may  be  repeated 
twice,  thrice,  or  oftener,  during  the  day,  care  being  taken  that  the 
sediment  from  the  solution  be  removed  before  the  drops  are  repeated. 
The  preparations  used  by  me  are  the  acetate  of  lead,  zinc,  alum,  or 
tannin  ;  but  the  first-named  has,  I  think,  answered  best.  This 
species  of  polypus  may  often  be  removed  in  a  week,  or  from  that  to 
a  fortnight ;  and,  to  prevent  any  congestion  in  the  tympanic  cavity, 
a  slight  discharge  from  the  surface  of  the  mastoid  process  has  gene- 
rally been  kept  up  during  the  employment  of  the  astringent  solu 
tion. 


132  THE    DISEASES    OF    THE    EAR. 

Cane  X.  Globular  ccUuIar  iwlypus ;  discharge  for  three  years; 
cured  hy  the  soJutlun  of  liquor  plumhi. — Miss  F.  A.,  aged  12,  of  a 
rather  -weakly  constitution,  Avas  brought  to  consult  nic  on  the  30th 
of  March,  1850.  Iler  mother  stated  that  she  had  been  dull  of  hear- 
ing during  several  years,  in  the  left  ear  ;  and  this  dulncss  has  of 
late  so  much  increased,  that  Avhen  the  right  ear  is  pressed  upon  the 
pillow,  she  cannot  hear  even  loud  voices.  During  the  last  three 
years  there  has  been  a  discharge  from  the  ear,  which  has  sometimes 
been  very  offensive,  and  at  times,  especially  in  the  morning,  it  has 
been  of  a  dark  color.  There  has  been  no  complaint  of  pain  in  the 
ear ;  but  a  tenderness  below  it  has  been  felt.  At  times  there  has 
been  pain  over  the  left  eyebrow,  extending  occasionally  to  that  side 
of  the  head.  On  examination,  it  was  found  that  the  watch  was 
heard  only  in  contact  with  the  car.  By  the  aid  of  the  speculum,  a 
globular  red  growth,  like  a  polypus,  Avas  discovered,  concealing  the 
membrana  tympani,  with  the  exception  of  a  small  semilunar  shaped 
portion  at  its  inferior  margin  (about  half  a  line  in  diameter  at  its 
centre),  which  was  quite  opaque.  As  this  growth  did  not  extend  far 
into  the  meatus, — as  it  was  of  a  deep  red  color,  and  its  surface  quite 
smooth,  it  presented  an  appearance  very  analogous  to  that  of  the 
thickened  mucous  membrane  of  the  t^nnpanum  ;  which,  as  has  been 
stated,  becomes  sometimes  so  much  hj-pertrophied,  as  to  project  into 
the  meatus,  and  occupy  a  position  nearer  to  the  orifice  than  the 
membrana  tympani  did  previous  to  its  destruction.  The  presence 
of  the  latter  membrane  was  in  this  case,  however,  ascertained  ;  by 
the  use  of  the  otoscope,  air  was  heard  to  enter  the  tympanic  cavity 
without  passing  into  the  meatus  ;  and  the  small  portion  of  the  mem- 
brana tympani  which  was  visible,  could  be  observed  to  be  pressed 
out,  and  rendered  tense  and  white,  when  the  tympanic  cavity  was 
filled  with  air.  It  was  clear,  therefore,  that  the  diseased  growth 
was  a  polypus. 

The  treatment  ■^\}iVS'\xQi\  consisted  in  applying  to  the  surface  of  the 
polypus,  thrice  daily,  a  solution  of  the  diacetate  of  lead  ;  and,  as  I 
was  not  to  have  the  opportunity  of  seeing  the  patient  for  two  or 
three  months,  it  appeared  desirable  that  the  solution  should  not  be 
so  strong  as  would  otherwise  have  been  advisable,  so  only  six  drops 
of  liquor  plumbi  were  added  to  an  ounce  of  water. 

June  18th. — The  discharge  has  nearly  disappeared,  and  examina- 
tion shows  the  polypus  to  be  reduced  to  the  size  of  a  large  pin's 


THE     EXTERNAL     MEATUS.  133 

head.     The  hearing  was  improved,   the  watch  heing  heard  at  two 
inches  instead  of  only  Avhen  in  contact. 

I  had  no  opportunity  of  seeing  this  patient  again;  hut  some  little 
time  after  the  last  visit,  I  heard  that  the  discharge  had  ceased,  and 
the  hearing  so  much  improved  that  she  was  considered  cured. 

Case  XI.  Globular  poll/pus  in  right  ear  broken  up  by  forceps,  and 
a  solution  of  liquor  plumbi  applied;  cure. — Master  A.  H.,  aged  16, 
was  first  seen  hy  me  on  the  13th  of  April,  1850.  Both  tonsils  were 
enlarged ;  he  had  a  tendency  to  glandular  enlargements  ;  and  was 
at  the  time  of  his  visit  far  from  being  in  strong  health.  The  history 
of  the  case  Avas  as  follows  : — At  six  years  of  age  he  had  an  attack 
of  scarlet  fever,  Avhich  left  him  dull  of  hearing,  a  dulness  that  has 
increased  during  the  last  two  years  and  a  half;  has  had  discharge 
of  an  offensive  character  from  the  right  ear  during  the  last  eighteen 
months. 

Right  ear. — On  inspection,  a  polypus  was  observed  at  the  inner 
extremity  of  the  meatus,  growing  from  its  upper  part,  near  to  the 
membrana  tympani.  The  polypus  was  red  and  globular,  with  a 
smooth  shining  surface.  The  discharge  removed  from  the  meatus 
was  white  like  milk,  not  viscid ;  and  it  consisted  of  rounded  cells 
similar  to  those  excreted  in  catarrhal  inflammation  of  the  mucous 
membrane  of  the  tympanum,  and  the  nuclei  of  which  were  rendered 
very  distinct  by  the  addition  of  acetic  acid.  By  aid  of  the  otoscope, 
air  is  heard  to  enter  the  tympanic  cavity ;  and  in  doing  so,  to  pro- 
duce a  loud  sound,  like  that  attendant  upon  the  sudden  distention  of 
a  bladder  by  air.  The  watch  was  not  heard  over  the  ear,  but  only 
when  pressed  upon  the  temple. 

Left  ear. — The  membrana  tympani  was  dull  on  its  surface,  and 
white.  Air  passed  into  the  tympanic  cavity,  producing  a  sound 
similar  to  that  in  the  right  ear.  Hearing  distance,  a  quarter  of  an 
inch. 

April  17th. — By  means  of  the  rectangular  forceps,  the  outer  part 
of  the  polypus  was  broken  up ;  it  was  very  sensitive,  and  bled 
slightly.  A  solution  of  diacetate  of  lead  in  water  (four  grains  to  the 
ounce)  was  ordered  to  be  dropped  into  the  ear  thrice  daily,  and  a 
cantharidine  cerate  was  applied  to  the  nape  of  the  neck. 

2oth. — The  discharge  much  diminished,  and  its  offensive  odor  has 
disappeared  ;  the  polypus  is  only  one-third  its  former  size,  and  the 
membrana  tympani  is  seen  beyond  its  lower  border. 


134  TlIK     DISEASES    OF    THE    EAR, 

May  4tli. — ^lucli  the  same ;  prescribed  a  solution  of  chloride  of 
zinc  (ten  grains  to  the  ounce)  to  be  dropped  inlo  the  ear. 

IGth. — The  discharge  has  disappeared ;  the  hearing  so  greatly 
improved  that  the  patient  thinks  he  sometimes  hears  quite  well ; 
the  roots  of  the  polypus  alone  remain.  The  treatment  was  con- 
tinued ;  and  when  I  last  saw  the  patient,  on  the  13th  September, 
he  was  quite  well. 

In  the  following  case,  I  adopted  a  more  active  plan  of  treatment. 
Being  aware,  from  actual  examination,  that  polypoid  growths  of  the 
nature  now  under  consideration  are  extremely  soft,  in  order  to  re- 
move them  more  rapidly,  I  resolved  to  apply  an  astringent  to  them 
of  much  greater  strength  than  those  previously  used ;  and  the  com- 
plete success  of  this  proceeding  was  very  manifest. 

Case  XII.  Grhhilar  cellular  polypus  destroyed  by  a  strong  solu- 
tion of  acetate  of  zinc. — Miss  T.,  aged  21,  of  fair  complexion,  and 
in  good  health,  applied  for  advice  on  January  13th,  1852.  The 
history  of  the  affection  is,  that  seventeen  years  ago,  after  an  abscess 
behind  the  right  ear,  its  hearing  power  greatly  diminished,  and  has 
never  returned.  Six  months  ago,  a  discharge  issued  from  this  ear, 
which  has  continued  without  intermission  to  the  present  period.  On 
examination  of  the  right  ear,  the  watch  could  be  heard  only  when 
in  contact,  and  the  meatus  contained  a  considerable  quantity  of  dis- 
charge, consisting  of  tenacious  thready  particles  of  mucus,  and 
mucous  cells.  At  the  inner  extremity  of  the  tube,  a  globular- 
shaped  polypus,  of  a  red  color,  was  discovered,  attached  to  the 
upper  part  of  the  membranous  meatus,  close  to  the  membrana  tym- 
pani,  which  it  wholly  concealed,  with  the  exception  of  a  small  semi- 
lunar shaped  portion  seen  at  its  lower  border. 

Left  ear. — Hearing  distance  one  inch.  Membrana  tympani  white 
like  cartilage. 

Treatment. — The  right  ear  to  be  syringed  out  Avith  tepid  water 
thrice  daily,  and,  after  each  operation,  four  minims  of  a  solution  of 
acetate  of  zinc  (forty  grains  to  the  ounce)  to  be  dropped  into  the 
ear.  A  small  portion  of  vesicating  paper  to  be  kept  over  each  mas- 
toid process. 

January  IStli. — Slight  })ain  Avas  felt  for  half  an  hour  after  three 
applications  of  the  drops  ;  and  yesterday  the  patient  complained  of 
a  sensation  as  if  the  ears  were  distended.  The  discharge  is  di- 
minished in  quantity.     The  polypus  had  a  grayish  hue,  bled  on 


THE    EXTERNAL    MEATUS.  135 

being  touched,  and  appeared  partially  broken  up.  Large  particles 
of  the  acetate  of  zinc  had  collected  on  the  surface  of  the  polypus. 

19th. — Polypus  smaller ;  no  discharge ;  has  had  a  good  deal  of 
ear-ache.    To  syringe  with  warm  water,  and  omit  the  use  of  the  drops. 

22d. — The  pain  is  gone  ;  there  is  no  discharge  ;  the  polypus  has 
wholly  disappeared.  The  membrana  tympani  is  now  seen  ;  its  upper 
and  posterior  part  is  Avhite  and  thick ;  at  its  anterior  part,  there  are 
two  small  apertures,  through  which  the  mucous  membrane  of  the 
tympanum  is  seen  to  be  red  and  thick  ;  the  hearing  has  improved : 
the  watch  is  now  heard  by  the  right  car  at  a  distance  of  three 
inches ;  by  the  left,  at  a  distance  of  two  inches.  Subsequent  re- 
ports from  this  patient  state  that  the  discharge  has  not  returned, 
and  that  the  hearing  continues  to  improve. 


CHAPTER   VII. 


THE    EXTERNAL    MEATUS  [concluded). 


TUMORS. 

OSSEOUS   TUMORS  —  STRUCTURE TWO   CLASSES — TREATMENT — CASES  —  MOLLUSCOUS 

TUMORS — STRUCTURE — EFFECTS  ON  THE  BONE — TREATMENT — CASE — CONCLUSION  OP 
THE  SUBJECT  OF  THE  DISEASES  OF  THE  EXTERNAL  MEATUS — TABULAR  VIEW  OF 
THE  MORBID  CONDITIONS  FOUND  IN  THE  MEATUS  EXTERXUS  IN  1013  DISSECTIONS. 


I.  Osseous  Tumors. 

However  little  it  may  have  hitherto  attracted  the  attention  of 
the  profession,  there  is  reason  to  suppose  that  the  growth  of  osseous 

Fig.  37. 


Two  Osseous  Tumors  projecting  from  the  anterior  and  posterior  walls  of  the  Meatus  Exter- 
nus,  leaving  a  small  triangular  aperture  below. 

tumors  in  the  external  meatus  of  the  ear  is  a   (li.><ease  of  no  unfre- 
quent  occurrence.     Such  tumors  appear  to  be  the  result  of  a  rheu- 


THE    EXTERNAL    MEATUS.  137 

matic  or  gouty  diathesis,  and  may  be  developed  in  any  portion  of 
the  length  of  the  tube  ;  but  the  part  from  which  they  most  com- 
monly originate  is  about  the  middle  third  of  the  passage.  In  one 
case,  however,  the  tumor  extended  beyond  the  outer  orifice  of  the 
osseous  meatus,  and  could  be  felt  by  placing  the  little  finger  at  the 
meatus.  Occasionally  the  posterior  wall  aftords  the  point  of  origin 
to  the  tumor,  and  then  it  nut  unfre({uently  resembles  a  simple  bulg- 
ing of  the  wall.  In  other  cases,  a  similar  tumor  is  also  developed 
from  the  anterior  part,  and  the  two  protuberances  meet  and  lie  in 
contact  in  the  middle,  leaving  an  inferior  and  superior  triangular 
space  in  the  place  of  the  original  opening  of  the  tube.  Sometimes 
the  external  surfaces  of  the  tumors  are  in  contact  for  nearly  the 
entire  length  ;  and  the  only  passage  is  a  small  orifice  below.  The 
tumor  may  also  grow  from  the  upper  surface  of  the  tube,  and,  by 
gradually  increasing  in  size,  almost  or  quite  fill  up  the  passage. 
Two  or  more  tumors,  again,  extend  sometimes  from  various  parts  of 
the  circumference  of  the  meatus,  and,  converging  towards  the 
centre,  fill  up  nearly  the  whole  cavity. 

As  far   as   my  opportunities   have   permitted  examination,  these 
tumors,  as  in  the   one   delineated  below,  appear  to  consist  of  ex- 

FiG.  38. 


The  vertical  section  of  the  External  Meatus  and  Osseous  Tumor,  from  without  inwards. 

tremely  hard  and  dense  bone.  In  one  case,  where  a  portion  of  bone 
was  denuded  of  membrane,  it  appeared  shiny,  white,  and  polished, 
like  ivory.  In  'another,  where,  under  the  misapprehension  of  the 
body  being  a  polypus,  caustic  had  been  applied,  the  bone  was  ex- 
posed, and  found  to  be  extremely  hard  and  devoid  of  sensibility. 
In  a  third  instance,  where  I  observed  the  membrane  to  be  absent, 


138  THE    DISEASES    OF    THE     EAR. 

there  was  a  thin  Layer  of  cartiUige  on  the  surface,  beneath  ^vhich 
the  bone  was  very  haril. 

The  tumors  are  usually  covered  by  the  lining  membrane  of  the 
meatus,  which  is  frequently  thick,  spongy,  and  less  sensitive  than 
is  natural.  "When,  by  irritation,  chronic  inflammation  is  set  up, 
this  membrane  pours  forth  a  discharge  whose  odor  is  most  offensive. 

The  development  of  these  tumors  is  frequently  unattended  with 
any  symptoms  calculated  to  attract  the  attention  of  the  patient ;  and 
therefore  it  is  only  Avhen  by  their  increase  of  size  they  act  as  an 
impediment  to  the  passage  of  the  sonorous  vibrations  to  the  mem- 
brana  tympani,  that  the  patient  is  inconvenienced  by  the  deafness, 
and  seeks  relief.  Deafness  may  result  in  these  cases,  first,  from  a 
collection  of  cerumen  or  epithelium  lodging  in  and  blocking  up  the 
small  passage  of  the  tube  left  unoccupied  by  the  tumors ;  secondly, 
a  drop  of  water  may  have  entered  the  ear  during  the  ordinary 
ablutions,  and  produced  the  same  effect ;  thirdly,  the  growth  of  the 
tumor  may  have  proceeded  unchecked  till  the  entire  cavity  of  the 
meatus  is  filled  up.  In  some,  cases,  however,  the  growth  of  the 
tumors  produces  a  feeling  of  distention  in  the  ear,  and  weight  in  the 
affected  side  of  the  head ;  while  in  others,  again,  they  appear  symp- 
tomatic of,  and  consequent  on,  exostosis  forming  in  the  deeper 
regions  of  the  ears ;  as,  for  instance,  in  the  tympanic  or  vestibular 
cavities, — a  condition  I  have  sometimes  detected  in  the  course  of  my 
dissections.  In  three  instances,  subsequently  cited,  there  seemed 
great  probability  of  this  being  the  case ;  and  the  distressing  noises 
and  sense  of  giddiness  may  probably  have  depended  upon  the  pres- 
sure exerted  on  the  expansion  of  the  auditory  nerve  by  an  exostosis 
in  the  vestibule. 

The  only  diseased  substance  with  which  the  tumors  are  likely  to 
be  confounded,  are  polypi ;  from  which,  however,  by  very  slight 
attention,  they  may  readily  be  discriminated.  When  inspected  by 
means  of  the  speculum,  the  polypus  is  seen  to  be  darker  in  color, 
and  glistening,  from  being  generally  lubricated  by  discharge ;  the 
osseous  tumor,  on  the  other  hand,  is  white ;  and  though  smooth,  free 
from  moisture.  The  base  of  the  polypus  is  also  generally  narrow, 
while  that  of  the  osseous  tumor  is  broad.  Any  doubt,  however,  is 
easily  removed  by  the  use  of  the  probe,  which  being  pressed  against 
the  bony  protuberance,  at  once  reveals  its  nature. 

The  disease  under  consideration  may  be  divided  into  two  classes. 

The  first  and  most  common  is  that  in  which  the  disease  appears 


THE     EXTERNAL    MEATUS.  139 

associated  with  congestion  of  the  mucous  membrane  of  the  ear. 
Most  of  the  patients  who  have  consulted  me  on  account  of  it  were 
in  the  habit  of  partaking  freely  of  stimulating  food  and  beverages. 

The  second  class  showed  symptoms  indicative  of  disease  in  the 
cavities  containing  the  expansion  of  the  auditory  nerve. 

I  Avill  now  proceed  to  point  out  some  of  the  modes  of  treatment. 
In  those  cases  where  the  tumors  occupy  a  considerable  space  in  the 
tube,  and  the  deafness  depends  upon  the  occlusion  of  the  canal  by  the 
accumulation  of  cerumen  or  epithelium,  it  is  important  at  once  to 
remove  it,  and  prevent  future  accumulations.  Where  water  pene- 
trates into  the  orifice  of  the  meatus,  and  fills  up  the  only  remaining 
pervious  portion  of  the  tube,  wool  should  be  placed  in  the  orifice  of 
the  meatus  when  the  patient  is  washing.  Should  the  membrane 
covering  the  tumor,  as  is  not  infrequent,  be  very  thick,  a  certain 
degree  of  relief  may  be  afforded  by  the  application  of  remedies  which 
shall  reduce  its  substance.  In  one  case  of  this  kind  I  was  enabled 
to  increase  the  size  of  the  tube,  and  much  improve  the  power  of 
hearing,  by  applying  a  solution  of  nitrate  of  silver. 

In  order  to  diminish  the  size  of  the  tumor  itself,  after  the  avoid- 
ance of  a  stimulating  diet,  the  l)cst  remedy  is  that  usually  employed 
by  surgeons  in  osseous  growths,  viz.,  iodine.  This  medicine  I  have 
prescribed  internally,  and  have  applied  it  behind  the  ear,  and  also 
to  the  surface  of  the  tumors,  with  o-reat  advantao;e.  In  some  cases 
large  tumors  Avere  so  much  reduced  as  to  allow  of  the  passage  of 
sonorous  vibrations ;  and  the  patients  regained  in  a  measure  that 
power  of  hearing  of  which  they  had  for  many  months  been  deprived. 

If  further  experience  should  establish  the  fact  that  these  tumors 
can  be  arrested  in  their  progress,  especially  at  that  early  period 
when  the  area  of  the  tube  is  but  slightly  encroached  upon,  much 
good  may  be  accomplished  and  much  suffering  prevented  or  relieved. 
And  while  there  are  many  weighty  objections  to  any  attempt  to  re- 
move these  tumors  by  operation  or  by  escharotics,  there  are  none  to 
the  use  of  iodine  and  the  otlier  absorbent  medicines,  from  which 
there  is  every  prospect,  by  persevering  use,  of  successful  results. 

In  consulting  authorities  on  this  interesting  subject,  the  only  ob- 
servations I  have  met  with  in  Kramer  are  the  following  : — 

"  They  (polypi)  are  even  of  cartilaginous  and  bony  hardness. 

"  A  stalactite-shaped  growth  hung  from  the  superior  surface  of 
the  meatus,  very  near  the  membrana  tympani,  and  was  of  so  remark- 


140  THE     DISEASES    OF    THE     EAR. 

able  a  bony  hardness  and  density,  that  it  was  impossible  to  pierce  it 
even  with  the  sharpest  knife. "^ 

Itard,  although  he  states  that  the  principal  causes  of  the  diminu- 
tion of  the  external  auditory  meatus  are  the  enlargement  of  the 
osseous,  cartilaginous,  and  membranous  structures  forming  the  mea- 
tus, says : — 

"  I  have  never  had  an  opportunity  of  observing  the  enlargement 
{gonjlement)  of  the  osseous  part  of  the  external  meatus,  and  the  ex- 
treme hardness  which  it  possesses  would  tend  to  make  this  kind  of 
alteration  very  rare."^ 

Case  I.  Tumors  in  each  ear,  with  deafness;  tuinors  diminished  in 
size;  deafness  cured. — June,  1848  :  D.  N.,  aged  Go,  for  the  last 
few  weeks  has  been  feeling  somewhat  deaf,  especially  in  the  loft  ear. 
This  deafness  is  increased  by  an  attack  of  cold,  to  Avhich  the  patient 
is  subject. 

Might  ear. — Meatus  partly  filled  Avith  bony  growths ;  one  rising 
from  the  anterior,  the  other  from  the  posterior  part  of  the  meatus. 
Membrana  tympani  dull.  Hearing  distance  less  than  that  of  a 
healthy  ear. 

Left  ear. — Meatus  blocked  up,  except  a  small  orifice,  by  three 
tumors  which  project  from  the  walls  of  the  meatus.  The  space  left 
between  these  bony  growths  was  occupied  by  a  collection  of  cerumen, 
which  being  removed,  the  power  of  hearing,  though  still  deficient, 
was  to  a  certain  extent  improved. 

Considering  that  every  attack  of  cold  increased  the  deafness,  and 
that  the  membrana  tympani  was  dull, — a  thickened  state  of  the 
mucous  membrane  seemed  also  indicated, — the  following  course  of 
treatment  was  adopted.  Alterative  doses  of  blue  pill  were  admi- 
nistered, and  the  surface  of  the  meatus  was  washed  with  a  solution 
of  argenti  nitras,  one  drachm  to  the  ounce,  every  fourth  or  fifth,  and 
afterwards  every  seventh  day.  This  course  of  treatment  was  con- 
tinued for  three  or  four  weeks,  and  the  power  of  hearing  was  largely 
extended.  The  plan  was  resumed  tlie  following  year,  and  the  ulti- 
mate result  was  a  perceptible  diminution  of  the  tumor,  arising,  as  I 
believe,  from  a  decrease  in  the  thickness  of  the  investin<i  mem- 
brane  ;  and  the  power  of  hearing  was  completely  restored. 

Case  II.    Tumors  in  both  ears;  deaf ness  produced  b>/  the  presence 


On  the  Nature  and  Treatment  of  Diseases  of  the  Ear.     Longman.    1S4".     P.  U7. 
'  Traite  des  Maladies  de  I'Oreille  et  de  lAudition.     1821.     Tome  i,  p.  328. 


THE     EXTERNAL     MEATUS. 


141 


of  a  drop  of  water  in  the  meatus. — July,  1846  :  E.  F.,  aged  60,  has 
been  so  deaf  in  the  right  ear,  for  some  years,  as  to  derive  little  use 


Fig.  39. 


Three  Osseous  Tumors  projecting  from  the  walls  of  the  Meatus. 

from  it.     Has  several  times  lately  become  suddenly  so  deaf  in  the 
left  ear  as  scarcely  to  be  able  to  hear  a  conversation.    These  attacks 

Fig.  40. 


) 


A  large  Osseous  Tumor  and  two  smaller  ones  in  the  Meatus  E.xternus. 

have  usually  come  on  in  the  morning  after  washing,  and  frequently 
lasted  for  some  hours. 


142  TUE     DISEASES     OF     THE     EAR. 

Right  ear. — Two  bonv  tumors  were  observed  in  the  meatus,  occu- 
pying about  one-half  of  its  calibre,     Membrana  tympani  dull. 

Left  ear,  meatus. — Extending  from  the  upper  part  of  the  meatus 
is  a  long  bony  tumor,  taking  up  two-thirds  its  calibre.  This  tumor 
is  covered  by  a  thick  soft  membrane,  excepting  at  one  point  of  about 
half  a  line  in  length,  and  a  quarter  of  a  line  in  breadth.  From  the 
anterior  and  posterior  parts  of  the  lower  half  of  the  tube  projected 
two  small  elevations  of  bone,  about  three-quarters  of  a  line  in  thick- 
ness, in  the  direction  of  the  large  tumor,  so  as  to  leave  but  a  very 
small  triangular  space  between  them.  This  space  was  the  only  open- 
ing by  which  the  sonorous  undulations  could  pass  to  the  membrana 
tympani ;  and  it  was  found  that,  during  the  operation  of  washing, 
it  was  liable  to  be  filled  up  by  water,  which  produced  temporary 
deafness.  The  opportunity  of  carrying  out  a  course  of  treatment 
for  the  diminution  of  the  tumors  was  not  given  to  me ;  but  by  adopt- 
ing means  to  prevent  the  entrance  of  water  into  the  meatus,  the  at- 
tacks of  deafness  were  entirely  prevented. 

Case  III.  Tumor  in  the  meatus  of  the  right  ear  ;  orifice  in  mem- 
brana tympani  of  left  ear. — Nov.  13,  1845  :  P.  H.,  aged  56,  eleven 
years  before,  when  in  Russia,  fell  asleep  in  a  garden.  The  next  day 
felt  severe  pain  in  the  left  car,  which  lasted  during  fourteen  days, 
when  matter  began  to  discharge.  Has  had  several  attacks  of  pain 
in  the  left  ear  since  that  period,  which  have  been  accompanied  by 
beatinrj  and  sinfrin"". 

About  six  months  ago,  being  then  in  the  AVest  Indies,  had  an 
attack  in  the  right  ear,  followed  by  a  diminution  in  the  power  of 
hearing,  but  there  was  no  discharge.  Two  months  ago  he  returned 
to  England,  and  entirely  recovered  the  use  of  the  right  ear,  hearing 
better  also  with  the  left.  Within  the  last  four  days  pain  came  on  in 
the  left  ear  and  rapidly  increased,  followed  by  pain  in  the  right  ear, 
and  so  great  an  extent  of  deafness  in  both  ears  as  to  require  him  to 
be  shouted  to. 

Right  ear,  meatus  externus. — The  middle  two-thirds  of  the  lower 
wall  are  occupied  with  a  bony  tumor  filling  half  the  calibre  of  the 
tube. 

Left  ear. — Meatus  externus  red,  and  covered  by  discharge.  Mem- 
brana tympani  white,  soft,  and  tliick,  witli  a  small  orifice,  through 
which  air  passes. 

Case  IV.  Osseous  tuinors  in  each  ear  ;  feeling  of  confusion  in  the 
head. — Nov.  4,  1848  :  T.  T.,  aged  38.     Last  year  deafness  gradu- 


THE     EXTERNAL     MEATUS.  143 

ally  came  on  in  the  left  ear,  with  occasional  attacks  of  deafness  in 
the  night.  This  deafness  has  of  late  very  much  increased,  and  been 
also  attended  with  a  feeling  of  confusion,  and  a  sense  of  oppression 
in  the  head. 

Right  ear. — Projecting  from  the  whole  of  the  anterior  and  poste- 
rior surfaces  of  the  external  meatus,  are  two  osseous  growths,  which 
come  into  contact  in  the  centre  of  the  tube.  Hearing  distance  one 
foot. 

Left  ear. — Two  similar  tumors  likewise  exist  in  the  meatus  of  this 

Fig.  41. 


Two  Osseous  Tumors  of  the  External  Meatus  in  contact  internally. 

ear  ;  but  at  the  superior  part  they  have  so  increased  as  to  be  in  con- 
tact throughout,  save  a  small  orifice  at  the  lower  part.  The  deaf- 
ness in  this  ear  has  been  greatly  increased  by  the  presence  of  a  small 
quantity  of  cerumefi,  which  had  filled  up  the  small  orifice  just  de- 
scribed, and  its  removal  gave  temporary  relief ;  but  it  Avas  evident 
that  the  tumors  would  go  on  increasing  until  the  entire  passage  of  the 
meatus  was  blocked,  unless  remedial  measures  were  at  once  adopted. 
For  these  no  opportunity  was  afforded  me. 

Case  V.  Large  tumor  in  left  ear,  causing  deafness ;  diminished 
hy  the  use  of  iodine. — Feb.  1849.  S.  P.,  aged  17,  states  that  deaf- 
ness commenced  in  the  left  ear,  about  two  years  and  a  half  ago, 
and  has  been  gradually  progressing,  till  at  length  he  cannot  hear 
at  all  with  that  ear.  Sometimes  there  is  a  violent  itching,  followed 
by  discharge,  and  the  tube  of  the  ear  is  so  sensitive,  that  the  least 


144 


THE    DISEASES     OF    THE    EAR. 


touch  causes  exquisite  pain.     There  is  also  a  continuously  unplea- 
sant sensation,  as  if  the  ear  -were  being  distended.     He  complains 
of  dulness  of  hearing  in  the  right  ear.     Has  been  to  various  sur- 
geons and  public  institutions,  but  without  obtaining  any  relief. 
Riglit  ear. — A  large  osseous  tumor  occupies  nearly  the  -vvhole  of 


Fig.  42. 


An  Osseous  Tumor  growing  from  the  Upper  Wall  of  the  Meatus,  and  occupying  nearly 
the  whole  of  its  calibre. 


the  meatus,  and  is  attached  to  its  upper  part.  It  is  covered  by  the 
dermoid  lininfr  of  the  meatus,  which  is  about  a  third  of  a  line  thick. 

Left  car. — Healthy. 

Tincture  of  iodine  Avas  applied  to  the  surface  of  the  tumor,  as  also 
behind  the  ear,  and  four  grains  of  iodide  of  potassium  were  given 
thrice  daily  for  between  two  and  three  months.  Great  relief  was 
the  result ;  the  size  of  the  tumor  diminished ;  the  power  of  hear- 
ing greatly  increased ;  the  tube  of  the  ear  lost  its  unnatural  sensi- 
bility ;  and  the  unpleasant  sensation  of  distention  completely  va- 
nished. 

Case  VI.  A  tumor  in  the  right  ear,  filling  nearly  the  entire  tube  ; 
slight  protHhcranees  in  the  left  ear. — Nov.  25,  1848  :  J.  S.,  aged  65, 
states  that  ten  years  ago  he  had  a  gathering  in  the  right  ear,  with 
great  pain  and  much  discharge.  Continued,  however,  to  hear  pretty 
well  until  witliin  about  a  month  previous  to  applying  to  me,  during 


THE    EXTERNAL     MEATUS.  145 

which  he  has  grown  so  very  deaf  that  he  cannot  hear,  unless  the 
speaker's  mouth  approaches  close  to  the  ear. 

Ri(jlit  car. — The  external  meatus  contained  a  collection  of  epithe- 
lium, on  the  removal  of  which  an  osseous  tumor  was  disclosed,  filling 
nearly  the  whole  of  the  tube.  The  tumor  projected  from  the  upper 
and  lateral  surfaces,  and  nearly  touched  the  lower  wall  of  the  tube. 
Watch  not  heard  in  contact  with  the  ear. 

Left  ear. — The  lower  wall  of  the  meatus  presents  two  slight  and 
quite  hard  elevations. 

Treatment. — Alterative  doses  of  blue  pills  were  prescribed,  and 
tincture  of  iodine  was  directed  to  be  applied  behind  the  cars.  The 
result  I  have  not  heard. 

Case  VII.  Tumor  in  the  right  ear  following  the  extraction  of  a 
polypus. — June,  1847 :  Rev.  J.  D.,  aged  47,  consulted  me  for  a 
continued  discharge  from  the  right  ear.  He  stated  that  twenty 
years  previously,  after  the  forcible  removal  of  a  collection  of  Avax 
from  the  right  ear,  he  experienced  great  pain,  followed  by  an  offen- 
sive discharge,  that  had  lasted  to  the  present  time.  On  examination, 
a  large,  red,  and  firm  polypus  was  perceived  to  fill  the  whole  of  the 
meatus,  nearly  as  far  as  the  orifice.     It  was  attached  to  the  wall  of 

Fig.  43. 


Osseous  Matter  developed  from  the  walls  of  the  Meatus  E.\ternus,  leaving  a  triangular 

space  in  the  centre. 

the  meatus,  near  to  the  membrana  tympani,  and  on  its  removal  the 
latter  was  found  to  be  very  thick  and  vascular,  with  a  small  orifice 
at  its  lower  part.     The  discharge  wholly  disappeared. 

10 


146  THE    DISEASES    OF    THE     EAR. 

In  July,  1857,  the  patient  again  consulted  me  on  account  of  a 
slight  return  of  the  discharge,  accompanied  by  some  degree  of  pain 
in  the  right  side  of  the  head,  with  an  unpleasant  sensation  of  fulness 
and  pressure  in  the  ear.  On  inspection,  the  meatus  was  found  con- 
tracted to  one-fourth  its  natural  size  by  the  growth  of  osseous  matter 
from  its  walls,  especially  anteriorly  and  posteriorly,  thus  leaving  a 
mere  triangular  opening,  through  which  only  the  central  part  of  the 
membrana  tympani  was  visible,  and  that  was  Avhite  and  thick, 

I  recommended  the  use  of  a  strong  solution  of  liquor  plumbi  to 
stop  the  discharge  from  the  tube,  and  the  application  of  the  tincture 
of  iodine  behind  the  ear. 

In  this  case  there  had  been  long  standing  disease  of  the  tympanic 
cavity,  membrana  tympani,  and  meatus,  consequent  on  local  injury. 
The  disease  was  attended  with  so  great  an  amount  of  deafness,  that 
it  appeared  as  if  the  cavities  containing  the  expansion  of  the  audi- 
tory nerve  might  also  be  implicated. 

Case  A'^III.  A  protuberance  of  the  lower  wall  of  the  meatus  in  the 
left  ear. — December,  1848  :  L.  E.  11.,  aged  25,  ten  years  previously 
experienced  a  singing  in  the  left  ear,  Avhich  during  a  cold  became 
much  worse,  and  was  attended  Avitli  a  feeling  of  numbness.  A  cold 
has  lately  aggravated  all  the  symptoms  in  the  left  ear,  and  called 
forth  a  noise  like  a  bell  in  the  right  ear. 

Right  ear. — Membrana  tympani  dull ;  hearing  distance  two  feet. 
Left  ear. — Meatus  contained  a  large  quantity  of  cerumen,  after 
the  removal  of  which  the  passage  was  observed  to  be  red.     At  the 
lower  wall  near  the  membrana  tympani  there  is  a  considerable  bulg- 
ing of  the  osseous  wall.     Hearing;  distance  half  an  inch. 

In  this  case  the  diminished  degree  of  hearing  in  the  left  ear  did 
not  depend  upon  the  enlargement  of  the  external  meatus,  for  there 
was  no  doubt  of  a  thickening  of  the  mucous  membrane  lining  the 
tympanic  cavity. 

Case  IX.  Osseous  tumor  in  the  external  meatus,  causing  a  collec- 
tion of  epidermis  and  serious  cerebral  st/mptoms ;  relieved. — J.  J.  S., 
Esq.,  aged  5G,  consulted  me  on  the  27th  April,  1850.  lie  stated 
that  when  a  boy  he  had  a  discharge  from  the  right  ear,  since  which 
period  he  has  been  deaf  at  times,  and  been  subject  to  a  noise  in  the 
ear,  together  with  a  feeling  of  pressure  on  the  head.  Two  months 
ago  he  complained  of  an  attack  of  toothache,  during  which  the  deaf- 
ness was  partially  relieved  ;  but  lately  it  lias  become  worse  again, 
accompanied  by  a  feeling  of  pressure  in  tlie  cars ;  he  has  also  had 


THE     EXTERNAL     MEATUS.  147 

frequent  attacks  of  giddiness  and  confusion  in  the  head.  On  exa- 
mining the  right  ear,  the  middle  part  of  the  meatus  was  seen  to  be 
occupied  by  a  bony  tumor  which  fills  the  whole  of  the  tube,  with  the 
exception  of  a  small  space  about  three-quarters  of  a  line  in  diameter, 
situated  at  its  superior  part.  This  space  was  observed  to  be  closed 
by  a  white  substance,  which,  on  being  touched  with  the  probe,  proved 
to  be  of  great  density.  As  it  appeared  probable  that  part,  at  least, 
of  the  symptoms  above  detailed  depended  upon  the  collection  of  epi- 
dermis behind  the  bony  tumor,  and  its  pressure  upon  the  membrana 
tympani,  it  was  thought  desirable  to  attempt  its  removal.  Small 
portions  Avere  picked  away  by  the  point  of  a  probe,  and  the  syringe 
was  used  ;  it  was,  however,  so  hard  that  only  minute  particles  could 
be  detached.  A  solution  of  carbonate  of  soda  Avas  directed  to  be 
applied  constantly  for  some  days,  and  then  a  further  quantity  was 
extracted,  Avhich  mitigated  the  symptoms.  By  pursuing  this  plan, 
the  whole  of  the  matter  beyond  the  tumors,  which  was  found  to  be 
epidermis,  was  got  rid  of ;  and  the  patient  not  only  heard  better, 
but  the  unpleasant  symptoms  of  giddiness  and  cerebral  irritation 
entirely  disappeared.  Judging  from  the  large  quantity  of  epidermis 
removed  in  comparison  with  the  small  space  between  the  tumor  and 
the  membrana  tympani,  that  substance  must  have  been  greatly  com- 
pressed, and  tlie  membrana  tympani  also  subjected  to  much  pressure. 
In  the  year  1852,  and  again  in  the  present  year,  the  same  gentle- 
man consulted  me  on  account  of  similar  symptoms,  which  were  wholly 
removed  by  the  use  of  the  syringe  alone. 


II,  Molluscous  Tumors. 

Molluscous  tumors  are  sometimes  formed  in  the  external  meatus, 
and  lead  to  very  serious  results.  I  first  met  with  these  tumors  when 
making  dissections  of  the  ear,  and  several  specimens  are  in  my 
possession,  which  well  illustrate  the  nature  of  the  disease.  These 
excrescences  seem  to  have  their  origin  in  the  dermis  of  the  meatus, 
and  they  gradually  increase  in  size  so  as  not  only  to  fill  the  Avhole 
of  the  meatus,  but  to  encroach  upon  and  cause  absorption  of  the 
bone.  Thus,  in  some  instances,  the  lower  osseous  wall  of  the 
meatus  is  affected,  and  in  part  absorbed,  while  in  others  the  tumor 
extends  upwards,  and  the  whole  of  the  upper  wall  of  the  meatus 
effaced  by  the  pressure  exerted  upon  it.     I  have  met  with  cases 


148 


TUE     DISEASES    OF    THE    EAR. 


wliicli  tlic  tumor  has  extended  into  the  cerebral  cavity.  These 
cases  are  liable  to  be  overlooked,  and  classed  "with  those  in  which 
there  is  a  simple  accumulation  of  epidermis  in  the  meatus. 


Fig.  44. 


Molluscous  Tumor  filling  the  whole  of  the  Meatus  Externus. 

The  treatment  of  molluscous  tumors  consists  in  removing  the 
large  mass  of  scales  contained  in  the  tumor,  and  afterwards  syringing 
the  meatus  abundantly  Avith  warm  water  twice  or  thrice  daily. 

Fig.  45. 


C.ivity  in  the  Mentus  Externus  from  which  a  Molluscous  Tumor  has  been  removed. 

Case.  Molluscous  tuino?'  in  the  external  meatus  ;  discharge  from 
he  ear. — Mr.  G.,  between  40  and  50,  consulted  me  for  a  discharge 


THE    EXTERNAL    MEATUS. 


149 


from  the  right  ear,  accompanied  by  deafness.  On  examination,  the 
meatus  Avas  observed  to  be  nearly  full  of  a  white  caseous-looking 
matter,  from  which  oozed  a  discharge.     By  persevering  use  of  the 


Fig.  46. 


Apertures  in  the  upper  wall  of  the  Meatus  Externus  communicating  with  the  Cerebral 
Cavity,  produced  by  a  Molluscous  Tumor. 

syringe,  aided  by  the  forceps,  a  large  Avhite  mass  was  removed, 
which  was  found  to  consist  of  layers  of  white  matter,  composed  of 
large  scales,  similar  to  those  of  other  molluscous  tumors.  On  the 
removal  of  the  mass  the  discharge  disappeared. 

In  bringing  to  a  conclusion  these  observations  on  the  diseases  of 
the  external  meatus,  it  will  be  well  to  draw  attention  to  the  morbid 
conditions  disclosed  by  the  dissection  of  1013  diseased  ears.  They 
were  as  folloAvs  : — 


Containing  a  collection  of  cerumen,           .......  71 

Containing  a  collection  of  cerumen  and  epidermis,  .....  9 

Distended  and  dilated  by  a  collection  of  cerumen,    .....  5 

Distended  and  dilated  by  a  collection  of  cerumen  and  epidermis,      .          .  1 

Containing  a  collection  of  cerumen  and  rye-seeds,    .....  2 

Containing  a  collection  of  cerumen,  the  osseous  walls  being  absorbed  in 

parts,    .............  3. 

Containing  a  collection  of  cerumen  and  epidermis,  the  osseous  walls  being 

absorbed  in  parts,           ..........  4 

Containing  a  collection  of  cerumen,  the  osseous  walls  being  absorbed  in 

parts,  so  as  to  expose  the  cavities  of  the  mastoid  cells,          ...  1 

Containing  a  collection  of  hairs,       ........  1 

Containing  a  collection  of  cotton-wool,     .......  1 


150  THE     DISEASES     OF     THE     EAR. 

Containing  a  molluscous  tumor 5 

Containing  a  molluscous  tumor,  the   osseous  walls  being  absorbed   in 

parts 3 

Containing  a  molluscous  tumor  which  projects  through  the  bone  into  the 

cerebral  cavity,     ...........  1 

Containing  a  molluscous  tumor  which  projects  into  the  mastoid  cells,       .  1 

Containing  a  collection  of  pus,          ........  10 

Containing  a  collection  of  pus  mixed  with  epidermis,        ....  1 

Having  polypi  growing  from  its  walls,      .......  1 

Having  polypi  growing  from  its  walls,  the  bone  being  carious,          .         .  1 

The  dermoid  layer  so  much  atrophied  as  to  leave  the  bone  denuded,         .  2 

The  dermoid  layer  hypertrophied,     ........  2 

The  dermoid  layer  congested,   .........  7 

The  dermoid  layer  soft,     ..........  1 

The  dermoid  layer  soft  and  red,        ........  2 

The  dermoid  layer  soft  and  detached  from  the  bone,         ....  2 

The  dermoid  layer  soft  and  thick,  the  bone  being  carious,        ...  1 

The  dermoid  layer  ulcerated,  the  bone  being  carious 1 

Osseous  walls  rough,          ..........  1 

Osseous  walls  carious,       ..........  7 

Osseous  walls  absorbed  in  parts,        ........  2 

Osseous  walls  presenting  an  orifice  superiorly,  ......  3 

Osseous  walls  presenting  an  orifice  inferiorly,  .         .         ....  1 

Osseous  canal  much  contracted,         ........  3 

Having  bony  growths  from  the  osseous  walls  :  canal  much  contracted.     .  14 


CHAPTER    VIII. 

THE     MEMBRANA     TYMPANI. 
STRUCTURE   AND    FUNCTIONS. 

THE  EPIDERMOID  LAYER — THE  DERMOID  LAYER — THE  FIBROUS  LAYERS — THE  RADIATE 
FIBROUS  LAYER — THE  CIRCULAR  FIBROUS  LAYER — THE  MUCOUS  LAYER — TENSOR  LIGA- 
MENT— FUNCTIONS  OF  THE  MEMBRANA  TYMPANI. 

Anatomical  Observations. — There  are  so  many  points  of  interest  in 
Pathology  connected  with  the  structure  of  the  membrana  tympani, 
which  bear  upon  its  morbid  conditions,  but  which  have  not  hitherto 
been  sufficiently  recognized,  that  the  subject  deserves  a  full  exami- 
nation. Looked  at  from  without  inwards,  the  membrana  tympani 
may  be  described  as  consisting  of  the  following  layers  : — 

1.  The  epidermis. 

2.  The  dermis. 

3.  The  fibrous  layer,  composed  of — 

a.  The  lamina  of  radiating  fibres. 
h.  The  lamina  of  circular  fibres. 

4.  The  mucous  membrane. 

The  epidermis  is  a  thin  layer,  covering  the  outer  surface  of  the 
dermoid  lamina  ;  it  is  continuous  with  the  epidermis  of  the  external 
meatus,  and,  when  subjected  to  the  process  of  maceration,  can  be 
removed  in  the  form  of  a  small  blind  pouch,  which  presents,  as  it 
were,  a  cast  of  the  meatus  and  of  the  external  surface  of  the  mem- 
brana tympani.  When  floating  in  water,  the  pouch  reassumos  the 
form  it  had  when  in  contact  with  other  tissues,  and  its  internal 
extremity  is  convex,  corresponding  with  the  external  concavity  of 
the  membrana  tympani.  The  layer  of  epidermis  forming  the  outer 
coat  of  the  membrana  tympani  is  thin,  and  in  the  living  subject  so 
transparent  that  the  dermoid  layer  can  be  distinctly  seen  through 
its  substance  ;  its  outer  surface  is  very  smooth,  and  capable  of  re- 


lo2  THE     DISEASES     OF    THE     EAR. 

fleeting  light ;  and  there  is  usually  seen  at  its  anterior  and  inferior 
part,  a  triangular  shining  spot. 

In  the  course  of  dissection,  I  have  more  than  once  found  this 
delicate  epidermis  to  be  the  only  layer  remaining,  over  portions  vary- 

FiG.  47. 


The  Triangular  Shining  Spot  at  the  anterior  and  inferior  part  of  the  outer  surface  of  the 

Membrana  Tympani. 

ing  from  a  line  to  a  line  and  half  in  breadth,  and  yet  appearing  to 
have  been  sufficient  to  close  the  cavity  of  the  tympanum  and  to  pre- 
serve the  power  of  hearing  nearly  perfect.  The  knowledge  of  this 
condition  of  the  membrana  tympani  ought  to  lead  to  a  cautious  use 
of  the  syringe  when  no  cerumen  is  present,  since  its  application  may 
cause  a  rupture  of  the  epidermis. 

The  dermoid  layer,  as  its  name  implies,  is  continuous  with  the 
dermis  lining  the  external  meatus,  and  is  situated  between  the  epi- 
dermis and  the  radiate  fibrous  layer.  It  is  extremely  thin,  and 
secretes  the  epidermis.  Previous  -to  the  publication  of  a  paper  by 
me  on  the  structure  of  the  membrana  tympani,  in  the  "  Philosophi- 
cal Transactions,"  for  1851,  it  had  l)een  supposed  that  the  epidermis 
was  secreted  by  the  radiate  fibrous  layer.  The  presence  of  the  der- 
mis is  best  demonstrated  by  carefully  dissecting,  under  water,  the 
membranous  meatus  from  the  upper  surface  of  the  osseous  tube,  as  far 
as  the  attachment  of  the  membrana  tympani ;  at  which  point  the  peri- 


THE     MEM  BR  AN  A     TYMPAXI.  153 

osteum  of  the  meatus  is  seen  to  become  continuous  with  the  radiate 
fibrous  hxmina;  this  being  cut  through,  the  dermoid  hiyer  is  detected 
passing  down  over  the  outer  surface  of  the  radiate  fibres,  and  sepa- 
rating them  from  the  epidermis.  If  the  upper  portion  of  tliis  hayer 
be  drawn  gently  downwards  by  one  hand,  by  means  of  a  fine  needle 
in  the  other,  the  delicate  cellular  tissue  which  connects  it  with  the 
fibrous  lamina  can  be  broken  up,  and  the  dermis  removed  entire. 
The  presence  of  this  lamina  may  also  be  shown  by  introducing  be- 
tween it  and  the  radiating  fibrous  layer,  at  the  superior  part  of  the 
membrana  tympani,  a  fine  bristle,  by  passing  which  down  the  cel- 
lular tissue  is  lacerated. 

In  a  healthy  state,  when  uninjected  by  blood  or  by  artificial 
means,  the  dermoid  lamina  is  thin  and  transparent,  and  its  structure, 
under  the  microscope,  looks  like  areolar  tissue.  When  injected, 
however,  this  membrane  is  seen  to  have  numerous  bloodvessels  rami- 
fying through  it,  so  as  to  foi-m  an  elaborate  plexus :  these  vessels, 
when  enlarged,  impart  the  red  appearance  to  the  surface  of  the  mem- 


FiG.  4S. 


The  Dermoid  Layer  of  the  Membrana  Tympani  continuous  with  the  Dermis  lining  the 
upper  wall  of  the  Meatus  Externus. 


brana  tympani  so  frequently  met  with  during  life.  It  is  upon  the 
supply  of  nerves  to  this  lamina  that  the  exquisite  sensibility  of  the 
membrana  tympani  depends. 

A  knowledge  of  the  existence  of  the  membrane  just  described  is 
of  interest  to  the  anatomist,  who  recognizes  in  it  the  secreting  organ 
of  the  epidermoid  layer  of  the  membrana  tympani ;  and  to  the  sur- 
geon, who  through  its  presence  is  enabled  to  understand  phenomena 
occurring  in  certain  diseases  of  the  ear.  There  are  pecidiar  diseased 
conditions  in  which  the  dermoid  layer  of  the  membrana  tympani  be- 
comes much  hypertrophied. 

The  Y*ro])cr  Jibroiis  layer  of  the  membrana  tympani  can  be  easily 
separated  into  two  lamina),  which  are  named  from  the  direction  of 
their  component  fibres.     Previous  to  describing  these  structures,  it 


154:  TUE     DISEASES     OF    THE     EAR. 

is  desirable  to  cite  the  opinions  of  eminent  anatomists  concerning 
them. 

In  the  Croonian  Lecture,  published  in  the  19th  volume  of  the 
"Philosophical  Transactions,"  Sir  Everard  Home  advanced  the 
opinion  that  the  membrana  tympani  in  the  human  subject  was  mus- 
cular. Ilis  words  are  :  "  When  viewed  in  a  microscope,  magnified 
twenty-three  times,  the  muscular  fibres  are  beautifully  conspicuous, 
and  appear  uniformly  the  same  throughout  the  whole  surface.  There 
being  no  central  tendon  as  in  the  diaphragm,  the  muscular  fibres 
appear  only  to  form  the  internal  layer  of  the  membrane,  and  are 
most  distinctly  seen  when  viewed  on  that  side."^  The  use  of  this 
radiated  muscle.  Sir  Everard  states,  is  "  to  give  those  difibrent  de- 
grees of  tension  to  the  membrane  which  empower  it  to  correspond 
with  the  variety  of  external  tremors."-  Since  the  first  publication 
of  this  opinion  as  to  the  muscularity  of  the  membrana  tympani,  ana- 
tomists, though  generally  conceding  that  it  is  fibrous,  have  widely 
differed  as  to  its  composition.  According  to  Mr.  Quain  and  Dr. 
Sharpey,  "  It  is  made  up  of  fine  closely-arranged  fibres,  the  greater 
number  of  which  radiate  from  near  the  centre  to  the  circumference ; 
but  within  these  are  circular  fibres,  which  are  more  scattered  and 
indistinct,  except  close  to  the  margin  of  the  membrane,  where  they 
form  a  dense,  almost  cartilaginous  ring."^  Mr.  "Wharton  Jones 
writes  :  "  The  proper  membrane  can  be  divided  into  two  layers — an 
outer  thin  one,  consisting  of  radiating  fibres,  and  an  inner  thicker 
layer,  which  is  less  distinctly  fibrous,  though  when  torn  it  does  indi- 
cate a  fibrous  disposition,  and  that  in  a  direction  opposite  to  the 
former.  .  .  .  The  fibres  which  cross  the  radiating  ones  are  more 
aggregated  at  the  centre  ;  they  run  parallel  with  the  handle  of  the 
malleus,  and  turn  round  its  extremity.  At  the  circumference  of  the 
proper  membrane,  there  is  a  thick,  firm,  ligamentous  or  cartilaginous 
ring,  which  is  fixed  in  the  groove  of  the  bone.  The  ligamentous 
ring  appears  to  be  formed  by  an  aggregation  of  the  circular  fibres 
interwoven  with  the  peripheral  extremities  of  the  radiating  ones."^ 

By  careful  dissection  the  fibrous  layers  of  the  membrana  tympani 
may  be  separated  into  two  distinct  laminse,  the  fibres  of  which  have 
no  intercommunication.  The  external  layer  may  be  called  the  radi- 
ate fibrous  lamina,  since  its  fibres  radiate  from  the  malleus  to  be  at- 

•  Loc.  cit.  p.  5.  '  Loc.  cit.  p.  11. 
»  Elements  of  Anatomy,  5th  Edition,  1848,  vol.  ii,  p.  932. 

*  Cyclopsedia  of  Anatomy  and  Physiology,  vol.  ii,  p.  545. 


THE     MEMBKANA    TYMPANI.  155 

taclied  to  the  cartilaginous  ring;  and  the  internal,  lk\Q  circular  fibrous 
lamina.  The  radiate  layer  is  the  thicker  and  stronger  of  the  two. 
So  readily  may  the  layers  be  separated  from  each  other,  that  they 
are  detached  Avith  more  facility  than  the  circular  layer  can  be  freed 
from  the  mucous  membrane. 

{a.)  The  radiate  fibrous  la^cr. — If  the  whole  of  the  membrana 
tympani  be  carefully  removed,  there  will  be  observed  at  its  cir- 
cumference a  white,  dense  ring,  apparently  cartilaginous,  which  is 
received  into  the  osseous  groove  of  the  temporal  bone  appropriated 
to  it.  It  Avill  be  remembered,  however,  that  this  groove  occupies 
only  about  five-sixths  of  the  circumference  of  the  inner  extremity 
of  the  meatus,  the  upper  sixth  being  smooth  instead  of  grooved. 
The  cartilaginous  ring  at  the  upper  part  is  attached  to  the  malleus, 
the  anterior  extremity  being  inserted  into  the  anterior,  and  the  pos- 
terior extremity  into  the  posterior,  part  of  the  cervix  of  this  bone : 
to  the  outer  surface  of  this  ring  is  attached  the  periosteum  lining 
the  external  meatus.  If  the  radiate  lamina  be  examined  with  a 
magnifying  power  of  ten  or  twelve  diameters,  fibres  will  be  observed 
whose  peripheries  are  attached  to  the  cartilaginous  ring,  and  their 
other  extremities  to  the  malleus.  The  uppermost  of  these  fibres, 
however,  must  be  excepted  from  the  observation  just  made  ;  for  in- 
stead of  passing  from  the  superior  part  of  the  ring  to  the  malleus, 
they  take  their  course  in  front  of  the  processus  brevis,  and  form  a 
distinct  layer  of  membrane  covering  its  outer  surface.  The  dispo- 
sition of  this  portion  of  the  radiating  fibrous  lamina  is  interesting 
alike  to  the  anatomist  and  surgeon,  for  it  is  observed  to  be  con- 
tinuous with  the  periosteal  lining  of  the  upper  part  of  the  external 

Fig.  49. 


The  Radiate  Fibrous  Layer  of  the  Membrana  Tympani. 

meatus.  Mr.  Shrapnell,  perceiving  that  this  portion  of  the  mem- 
brana tympani  Avas  not  so  tense  as  the  rest,  considered  it  to  be  a 
distinct  structure,  and  named  it  the  "membrana  flaccida." 

Directly  below  the  processus  brevis  of  the  malleus,  the  radiating 
fibres  are  attached  to  the  ridge  occupying  the  external  surface  of 


156 


THE    DISEASES     OF    THE     EAR. 


the  bone ;  but  at  4his  part  the  fibres  from  each  half  of  the  mcm- 
brana  tympani  are  inserted  so  near  to  each  other  that  no  portion  of 
the  malleus  is  visible  -when  viewed  exteriorly.  Towards  the  inferior 
extremity  of  the  long  process,  however,  the  fibres  being  attached  to 
the  sides  and  not  to  the  anterior  surface,  a  small  portion  of  the  ex- 
ternal surface  of  the  long  process,  at  its  inferior  part,  is  left  bare 
and  in  contact  with  the  dermoid  layer  ;  as  may  be  distinctly  seen  in 

Fig.  50. 


The  Fibres  composing  the  Radiate  Fibrous  Lamina  (magnified  about  300  diameters).' 

the  healthy  living  ear  by  the  aid  of  the  speculum  auris  and  a  mag- 
nifying lens.     The  fibres  extending  from  the  malleus,  and  forming 


Fig.  51. 


The  Radiate  Fibrous  Lamina ;  external  surface  displajing  the  peculiar  markings  caused 
by  the  interlacement  of  the  fibres. 

the  posterior,  are  one-fourth  larger  than  those  forming  the  anterior 
segment  of  the  membrane.     The  thickest  part  of  this  layer  sur- 


'  In  the  other  drawings  from  the  microscope,  the  same  magnifying  power  was  used. 


THE    MEMBRANA    TYMPANI. 


157 


rounds  the  extremity  of  the  long  process  of  the  malleus,  and  the 
most  attenuated  lies  bet-ween  the  posterior  margin  of  the  long  pro- 
cess of  the  malleus  and  the  circumference  of  the  membrana  tym- 
pani. 

Structure  of  the  radiate  lamina. — The  fibres  composing  the  ra- 
diate lamina,  when  examined  in  a  fresh  state  by  the  microscope,  are 
translucent,  and,  with  the  exception  of  a  few  transparent  globules, 
present  no  peculiarity  of  structure.  The  longitudinal  parallel  Avavy 
lines,  however,  characteristic  of  ordinary  fibrous  membranes,  are 
absent.  The  fibres  are  flat,  and  vary  from  40'ou  to  gj>g^  of  an  inch 
in  breadth.  In  passing  from  the  circular  cartilage  to  the  malleus 
these  fibres  interlace,  giving  rise  to  the  peculiar  diamond-shaped 
markings  observable  on  the  outer  surface  of  the  membrane.  When 
treated  with  acetic  acid,  this  lamina  becomes  opaque,  and  sometimes, 

Fig.  52. 


m^r  \k'MM^ 


ijlf 


'1 


'^^pfii^ii 


The  Radiate  Fibrous  Lamina,  after  having  been  treated  with  Acetic  Acid. 

but  not  invariably,  elongated  oval  nuclei  are  detected,  the  long  axes 
of  which  correspond  with  the  course  of  the  fibres.  In  no  instance, 
liowever,  was  an  oval  nucleus  visible  in  an  isolated  fibre. 


Fig.  53. 


The  Circular  Cartilaginous  Band,  after  having  been  treated  by  Acetic  Acid. 

The  circular  white  hand  at  the  circumference  of  the  radiate  fibres 
consists  of  a  firm,  slightly  elastic  mass  of  tissue,  and  presents  an  in- 
distinct appearance  of  fibres  intermixed  with  oval-shaped  nuclei. 


158  THE     DISEASES    OF    THE     EAR. 

Under  acetic  acid  this  structure  loses  its  white  aspect,  becomes 
translucent,  and  discloses  a  great  number  of  the  oval  nuclei. 

(b.)  The  circular  Jibrous  lamina. — This  membrane,  as  previously 
stated,  is  attached  to  the  radiating  fibres  by  fine  cellular  tissue,  and 
can  be  readily  separated ;  for,  as  before  observed,  the  fibres  of  each 
lamina  are  quite  distinct  and  never  intermingle.  As  its  name  im- 
plies, this  lamina  consists  of  circular  fibres,  which  are  firm  and 
strong  at  the  circumference,  but  so  attenuated  towards  the  centre, 
as  to  be  detected  only  by  careful  observation.  The  strong  fibres  at 
the  circumference  of  the  layer  form  a  complete  circle,  and  are  at- 
attachcd  to  each  side  of  the  body  of  the  malleus,  and  to  the  sides  of 
the  upper  third  of  the  processus  longus.     When  closely  examined 

Fig.  54. 


^^ 


The  External  Surface  of  the  Circular  Fibrous  Lamina     the  fibres  being  attached  to 
the  Processus  Longus  of  the  Malleus.     (Slightly  magnified.) 

by  a  magnifying  power  of  thirty  to  forty  diameters,  the  circular 
fibres  are  seen  to  be  intersected  by  others  of  an  extremely  delicate 
character,  which,  increasing  in  number  towards  the  centre  of  the 
lamina,  become  there  so  intimately  blended  with  the  circular  fibres 
that  the  latter  are  not  easily  distinguishable.  The  central  thin  por- 
tion of  the  circular  lamina  is  not  attached  to  the  malleus,  but  the 
fibres  from  each  side  are  continuous,  and  form  a  membranous  layer 
by  a  series  of  concentric  fibrous  circles  ;  the  outer  surfiice  being  in 
contact  with  the  inner  surface  of  the  lower  half  of  the  long  process 
of  the  malleus,  to  which  it  adheres  by  loose  cellular  tissue.  The 
circular  fibrous  lamina  is  entirely  unconnected  with  the  cartilagi- 
nous ring  into  which  the  radiating  fibres  are  inserted  ;  but  is  con- 
tinuous with,  and  may  be  considered  a  modification  of,  tlie  periosteal 
lining  of  the  tympanic  cavity.  When  the  lamina  of  circular  fibres 
is  detached  from  the  radiating  layer,  it  will  be  found  slightly  con- 
cave externally,  though  less  so  than  the  outer  layer.  In  its  sepa- 
rate condition  it  is  also  not  quite  so  concave  as  when  it  was  con- 
nected with  the  inner  surface  of  the  radiating  fibres ;  but  when  its 
central  portion  is  pressed  inwards,  so  as  to  increase  the  concavity. 


T  n  E     M  E  M  B  R  A  X  A     T  Y  M  P  A  N  I. 


159 


its  inherent  elasticity  causes  it  quickly  to  resume  its  former  saucer- 
like shape.     If  the  two  layers,  when  detached,  be  placed  side  by 


Fig.  55. 


The  Internal  Surface  of  the  Circular  Fibrous  Lamina :  the  Long  Process  of  the  Mal- 
leus is  seen  through  the  translucent  central  part.      (Slightly  magnified.) 

side,    the    greater   degree   of  external   concavity   in   the    radiating 
fibrous  layer  is  very  perceptible. 

Structure  of  the  circular  lamina. — When  highly  magnified,  the 
fibres  of  the  circular  lamina  are  found  to  be  smaller  than  those  of  the 
radiate  fibrous  layer,  and  to  vary  from  the  6000th  to  the  10,000th 
of  an  inch  in  breadth.  The  outer  fibres  run  parallel  with  each  other, 
and  do  not  interlace  ;  they  are  diaphonous,  and  free  from  any  wavy 
longitudinal  lines.    Under  acetic  acid,  the  fibres  enlarge  and  assume 

Fig.  56. 


The  Fibres  composing  the  Circular  Fibrous  Lamina. 

a  certain  degree  of  opacity  ;  and  in  some  instances  this  lamina  also 
presents  distinct  oval  nuclei  elongated  in  the  direction  of  its  fibres  ; 
but  as  in  the  radiate  lamina,  never  in  the  separate  fibres,  and  most 
commonly  they  are  not  present. 

It  is  often  not  easy  to  decide  Avhether  a  structure  is  muscular : 
hence  doubts  may  arise  as  to  the  true  nature  of  the  two  fibrous 
laminse  of  the  membrana  tympani.  My  own  researches  do  not  seem 
to  favor  the  view  of  that  membrane  being  a  contractile  tissue.     The 


160 


THE     DISEASES    OF    THE    EAR. 


facts  -vvliicli  appear  to  militate  against  the  idea  of  its  being  muscu- 
lar, arc  : — 

1st.  The  absence  of  distinct  nuclei  in  the  fibres. 


Fig. 


The  Fibres  of  the  Circular  Fibrous  Lamina,  treated  with  Acetic  Acid. 

2d.  The  great  denseness  and  hardness  of  the  latter,  and  their  firm 
and  unyielding  structure,  they  being  so  strong  as  to  be  Avith  diflH- 
culty  torn  across. 

(c.)  The  mucous  membrane  forming  the  inner  layer  of  the  mem- 
brana  tympani  is,  in  the  healthy  ear,  so  extremely  thin  as  to  be  with 
difficulty  detected  ;  though  by  careful  dissection  it  may  be  removed 
entire  from  the  inner  surface  of  the  circular  fibres,  with  which  it  is 
connected  with  considerable  firmness  by  fine  cellular  tissue. 

It  will  now  be  evident  that  of  all  the  laminte  Avhich  constitute  the 
membrana  tympani,  not  one  is  proper  to  that  organ  ;  all  of  them 
being  directly  continuous  with  other  structures,  of  which  they  appear 
to  be  modifications.     Thus  : — 

Fig.  58. 


The  Radiate  Fibrous  Lamina,  the  Circular  Fibrous  Lamina,  and  the  IMucous  Membrane  of 
the  Membrana  Tympani,  seen  to  be  continuous  with  the  other  structures.  (Slightly 
magnified.) 


1st.  The  epidermis  is  continuous  with  that   lining  the  external 
meatus. 

2d.  The  dermis  is  continuous  with  the  dermis  of  the  meatus. 


THE    MEM  BR  AN  A    TYMPANI.  161 

3d.  The  fibrous  lamina  consists  of  the  radiate  fibrous  lamina, 
which  is  a  prolongation  of  the  periosteal  lining  of  the  external 
meatus ;  and  the  circular  fibrous  lamiiia,  a  prolongation  of  the  peri- 
osteum of  the  tympanum. 

4th.  The  layer  of  mucous  membrane  forms  part  of  the  lining  of 
the  tympanic  cavity. 

Previous  to  considering  the  functions  of  the  fibrous  laminae  of  the 
membrana  tympani,  it  is  desirable  to  advert  to  another  point  in  the 
structure  and  relations  of  this  organ.  It  has  been  already  stated 
that  the  membrana  tympani  is  attached,  at  its  circumference,  to  the 
temporal  bone,  and,  at  its  central  part,  to  the  malleus,  which  latter 
bone  is  so  suspended  by  means  of  the  processus  gracilis  and  the 
short  process  of  the  incus,  that  the  long  process  can  move  inwards 
towards  the  tympanic  cavity,  and  outwards  towards  the  meatus.  It 
must  be  evident,  therefore,  that  in  order  to  prevent  the  concave 
membrana  tympani,  with  the  above  attachments,  from  remaining  in 
a  state  of  relaxation,  either  the  tensor  tympani  muscle  must  be  in  a 
state  of  continual  contraction,  or  some  other  provision  must  exist 
for  retaining  the  membrana  tympani  in  the  moderately  tense  con- 
dition fitting  it  to  receive  the  sonorous  undulations.  This  provision 
actually  exists,  and,  as  far  as  I  am  aware,  has  hitherto  escaped  the 
attention  of  anatomists :  it  is  the  tensor  ligament  of  the  membrana 
tympani. 

The  ligament  in  question  is  about  three-fourths  of  a  line  in  length, 
and  is  attached  internally  to  the  cochlcariform  process,  and  exter- 
nally to  that  part  of  the  inner  surface  of  the  malleus  where  the  long 
process  joins  the  neck.      In  the   interior  of  this  ligament,  which 

Fic  5'J. 


The  Attachments  of  the  Tensor  Tympani  Ligament ;   the  tendon  of  the  Tensor  Tymyiani 
Muscle  is  drawn  upwards  so  as  to  leave  the  ligament  isolated.     (Slightly  magnified.) 

is  tubiform,  is  placed  the  tendon  of  the  tensor  tympani  muscle. 
Anteriorly  the  ligament  is  thin,  consisting  of  very  delicate  fibres ; 
but  the  remainder  is  thick,  dense,  and  composed  of  firm  ligamentous 

11 


162  THE    DISEASES     OF    THE     EAR. 

tissue.  So  long  as  it  remains  entire  and  the  membrana  tympani 
uninjured,  the  latter  structure  retains  its  natural  degree  of  con- 
cavity and  tenseness ;  but  when  the  ligament  is  cut  through,  or 
there  is  a  solution  of  continuity,  resulting  from  disease,  the  mem- 
brana tympani  becomes  very  flaccid,  even  though  the  tendon  of  the 
tensor  tympani  muscle  remains  entire.  When  the  tensor  tympani 
muscle  is  pulled,  in  a  preparation  of  the  parts,  the  membrana  tym- 
pani is  rendered  very  tense,  and  the  tensor  tympani  ligament  re- 
laxes ;  but  so  soon  as  the  muscle  relaxes,  the  membrana  tympani 
returns  to  its  original  state,  and  the  ligament  again  becomes  tense. 

On  the  functions  of  the  Jibrous  lamina'  of  the  membrana  tympani. 
— It  is  obvious  that  one  use  of  the  fibrous  laminse  of  the  membrana 
tympani  is  to  present  a  firm  but  delicate  membranous  septum  for  the 
reception  of  sonorous  undulations.  The  arrangement  of  the  two 
sets  of  fibres  at  right  angles  to  each  other,  has  the  efi'ect  of  impart- 
ing great  strength,  combined  with  extreme  delicacy  and  tenuity,  to 
the  membrane.  As  stated,  there  is  no  evidence  to  prove  that  the 
fibres  of  which  the  membi'ana  tympani  is  composed  possess  in  them- 
selves any  contractile  power  ;  neither  do  the  component  fibres  of  the 
laminixi  appear  to  evince  more  than  an  extremely  slight  degree  of 
elasticity.  An  examination,  however  of  the  structure  after  death, 
shows  that  it  has  an  inherent  power  of  returning  to  its  natural  state 
after  being  unusually  distended.  Thus,  if  the  membrana  tympani  be 
exposed  without  interfering  Avith  its  natural  state  of  tension,  and  the 
canal  containing  the  tensor  tympani  muscle  be  laid  open,  so  that  the 
muscle  can  be  drawn  towards  its  origin,  the  external  concavity  of 
the  membrana  tympani  can  be  increased  until  it  becomes  very  tense  ; 
but  as  soon  as  the  muscle  is  let  go,  the  membrana  tympani  will  be 
observed  to  resume  its  former  condition.  This  action  is  explainable 
partly  by  the  slight  elasticity  of  the  circular  cartilaginous  band,  into 
which  the  peripheral  extremities  of  the  radiating  fibres  are  inserted, 
and  partly  by  the  slight  elasticity  of  these  fibres  themselves  ;  but  more 
especially  by  the  peculiar  arrangement  of  the  circular  fibrous  lamina, 
which  has  always  a  tendency,  Avhen  left  to  itself,  to  assume  a  more 
shallow  form.  Thus  when  the  membrane  is  rendered  very  concave, 
the  circular  fibres  are  slightly  separated  from  each  other ;  but  when 
the  extra  tension  ceases,  the  fibres  intersecting  the  circular  ones  aid 
in  drawing  the  latter  together  again. 

The  disposition  of  the  central  region  of  the  circular  lamina  also 
assists  it  in  bringing  back  the  membrana  tympani  to  its  natural 


THE     MEMBRANA    TYMPANI.  163 

State  after  tension  hj  the  tensor  tjmpani  muscle.  It  has  been 
stated  that  the  middle  part  of  these  circular  fibres,  instead  of  being 
attached  to  the  handle  of  the  malleus,  is  applied  against  its  inner 
surfjice,  and  thus  the  membrane  is  further  rendered  tense  by  the 
pressure  of  the  long  process  of  the  malleus  against  its  outer  surface 
during  the  action  of  the  tensor  tympani  muscle ;  and  when  this 
muscle  ceases  to  act,  the  central  part  of  the  circular  layer  reacts  on 
the  malleus  and  constrains  it  to  resume  its  usual  position.  Besides 
the  office  of  bringing  the  membrana  tympani  to  its  natural  state 
after  the  action  of  the  tensor  tympani  muscle,  the  circular  fibrous 
layer  would  appear  to  be  always  acting  as  an  antagonist  to  the 
tensor  tympani  ligament ;  so  that  by  the  continued  action  of  these 
two  tissues — the  one  drawing  it  inwards,  the  other  outwards — the 
membrana  tympani  is  kept  in  a  state  adapted  to  receive  all  the  ordi- 
nary sonorous  undulations,  independent  of  any  exercise  of  muscular 
power. 

T/ie  functions  of  the  memhrana  tympani. — Anatomists  generally 
consider  that  the  use  of  the  membrana  tympani  is  to  receive  the 
sonorous  undulations  from  the  air  of  the  meatus,  and  conduct  them 
to  the  ossicles,  by  which  they  are  conveyed  to  the  labyrinth. 
Whether  vibrations  are  conducted  to  the  labyrinth  through  two 
media,  or  through  the  air  alone,  there  can  be  no  doubt  that  the 
membrana  tympani  is  the  agent  whereby  the  vibrations  are  con 
veyed  from  the  meatus  externus  to  the  tympanum.  I  shall,  in  a 
future  part  of  this  volume,  try  to  prove  that  another  function  of  the 
membrana  tympani  is,  in  conjunction  with  the  muscles  and  bones  of 
the  tympanum,  to  act  as  the  analogue  of  the  iris  of  the  eye  :  and 
thus,  firstly,  shut  out  from  the  internal  ear,  or  at  least  modify,  the 
effect  of  loud  vibrations  ;  and,  secondly,  render  the  ear  susceptible 
of  the  more  delicate  undulations. 

Whatever  opinion  may  be  held  respecting  the  functions  of  the 
membrana  tympani,  there  can  be  no  doubt  that  its  integrity  is 
essential  to  the  due  performance  of  its  functions,  as  also  that  it 
should  retain  its  natural  degree  of  resiliency,  and  that  its  muscles 
should  be  able  to  move  it  with  ease. 


CHAPTER    IX. 


THE   MEM  BR  AN  A   TYMPANI   {continued). 

THE  EPIDEUMOID  LAYER — DERMOID  LAYER — {(l)    AC'fTE  IXFLAM JIATIOX — TREATMENT — 

CASES (A)  CHRONIC  INFLAMMATION — CASES — (c)      ULCERATION — CASES.    FIBROUS 

LAMINAE — {a)     ACUTE  INFLAMMATION — {!))     CHRONIC  INFLAMMATION — {c)    ULCERATION 

{fl)    CALCAREOUS  DEGENERATION — (c)  RELAXATION  OF  THE  MEMBRANA  TYMI'ANI — 

TREATMENT — CASES. 

In  describing  tlie  diseases  of  tlie  membrana  tympani,  I  shall  speak 
in  succession  of  its  epidermoid,  dermoid,  and  fibrous  layers,  leaving 
the  consideration  of  the  mucous  layer  till  the  diseases  of  the  tym- 
panic cavity  come  under  review. 

I.  The  Epidermoid  Layer. — This  layer  is  sometimes  secreted  in 
such  large  quantities  as  to  form  a  mass  several  lines  in  thickness 
on  the  outer  surface  of  the  dermis.  In  some  cases  I  have  known 
this  mass  to  be  composed  of  six  or  seven  lamint^,  closely  packed 
upon  each  other.     The  symptoms  attendant  upon  this  accumulation 

Fig.  60. 


I  '■  '  %^_ 


Epidermoid  Layer  of  the  Membrana  Tympani  liypertroiihied.  (Magnified  three  diameters.) 

are  analogous  to  those  of  accumulation  of  epidermis  in  the  meatus  ; 
tlicre  is  also  often  a  great  degree  of  cerebral  irritation  from  the  pres- 
sure on  the  chain  of  ossicles.  The  treatment  is  similar  to  that  em- 
ployed ■where  there  is  accumulation  of  epidermis  in  the  meatus  exter- 
nus.  A  syringe  and  warm  water  arc  usually  sufficient  to  loosen  and 
bring  away  the  mass.  Should  they  not  be  so,  a  few  drops  of  water 
or  soap  and  water,  dropped  into  the  meatus  for  a  day  or  two,  will 


THE     MEM  BR  AN  A     TYMPANI.  165 

loosen  and  facilitate  the  removal  of  the  mass.  As  a  general  rule, 
the  symptoms  of  deafness  and  discomfort  in  the  head  •wholly  dis- 
appear with  the  extraction  of  the  collection. 

II.  The  Dermoid  Layer. — This  layer  of  the  membrana  tympani, 
like  the  dermis  of  the  meatus,  is  subject  to  acute  and  chronic  inflam- 
mation, and  also  to  ulceration.  On  account  of  the  intimate  relations 
existing  between  the  dermoid  and  fibrous  layers  of  the  membrana 
tympani,  it  is  of  great  importance  to  put  a  stop  to  these  affections 
of  the  dermis,  since  they  are  apt  to  be  prolonged  to  the  deeper- 
seated  layers  of  the  organ. 

[a.)    ACUTE   INFLAMMATION    OF    THE    DERMIS. 

Acute  inflammation  of  the  dermis  usually  occurs  in  debilitated 
subjects,  and  is  produced  by  the  application  of  cold,  or  cold  water, 
or  any  foreign  body  to  the  surface.  The  exciting  causes  are  sudden 
exposure  to  cold  air  after  being  in  a  warm  room,  or  cold  water  find- 
ing its  way  into  the  ear  while  bathing  ;  often  also  it  arises  from  the 
extension  of  inflammation  from  the  dermis  covering  the  meatus. 
The  symptoms  of  this  kind  of  inflammation  are  slight  pain  at  the 
bottom  of  the  meatus  (aggravated  by  coughing,  sneezing,  and  at 
times  b}'  swallowing),  also  not  unfrequently  an  itching,  with  slight 
dulness  of  hearing.  On  examination,  the  outer  surface  of  the  mem- 
brana tympani  is  seen  to  be  dull,  and  the  dermoid  layer  opaque ;  its 
bloodvessels  being  distended  with  blood.  All  the  vessels  bordering 
on  the  malleus  are  very  much  larger  than  natural,  and  frequently 
form  tAvo  red  lines,  one  running  on  each  side  of  the  long  process  of 
the  malleus.  After  a  few  days  a  discharge  of  mucus  often  takes 
place.  This  affection,  if  left  unsubdued,  is  apt  to  advance  to  ulcera- 
tion, and  the  fibrous  layers  are  also  liable  to  be  destroyed. 

Treatment. — The  treatment  is  very  similar  to  that  for  acute  in- 
flammation of  the  dermoid  meatus.  One  or  more  leeches  should  be 
applied  to  the  margin  of  the  orifice  of  the  meatus,  warm  water  should 
be  syringed  into  it  thrice  or  oftener  daily,  hot  fomentations  used  all 
around  the  ear,  and,  if  requisite,  aperient  medicines  and  calomel  ad- 
ministered. Most  usually  the  inflammation  (seldom  accompanied 
by  discharge,  though  a  small  quantit}^  sometimes  issues  from  the 
surface  of  the  membrane)  soon  succumbs  to  this  treatment,  and  the 
fibrous  lamince  escape  uninjured. 


166  THE     DISEASES     OF    TUE     EAR. 

Case  I,  Acute  injlammation  of  the  dermoid  layer  of  the  memhrana 
tympani. — G.  W.,  Esq.,  aged  00,  consulted  me  on  February  15th, 
1858,  on  account  of  pain  in  his  right  ear. 

History. — Witliout  assignable  cause,  slight  pain  occurred  in  the 
right  ear  several  days  ago,  which  has  remained  till  now,  being  aggra- 
vated at  times.  It  is  increased  by  coughing,  and  slightly  when  swal- 
lowing. A  sensation  of  fulness  is  also  complained  of.  On  examina- 
tion^ I  found  the  dermoid  layer  of  each  membrana  tympani  to  be 
more  opaque  than  natural,  and  numerous  bloodvessels,  especially  at 
the  upper  part,  were  observed  to  be  distended  with  blood.  There 
was  but  slight  diminution  in  the  power  of  hearing. 

Treatment. — As  the  pain  was  not  very  severe,  the  ear  was  ordered 
to  be  syringed  out  with  warm  water  twice  daily,  a  linseed-meal  poul- 
tice to  be  applied  over  the  ear  at  night,  and  a  stimulating  liquid  to 
be  rubbed  over  the  back  of  the  ear.  The  pain  gradually  ceased,  and 
the  membrane  returned  to  its  natural  state. 

Case  II.  Acute  inflammation  of  the  dermoid  layer  of  the  memhrana 
tyynpani. — B.  S.,  Esq.,  a  medical  man,  aged  48,  saw  me  in  February, 
1852. 

History. — When  a  student,  twenty-six  years  previously,  he  had 
an  attack  of  cold,  and  became  suddenly  deaf  in  both  ears,  but  re- 
covered in  the  course  of  two  months.  Sixteen  years  ago,  had  an 
attack  of  vertigo,  and  suddenly  lost  the  use  of  the  left  ear  ;  the 
hearing  partially  returned,  but  still  remains  dull.  A  fortnight  be- 
fore consulting  me,  he  had  relaxation  of  the  throat,  with  an  uncom- 
fortable feeling  in  the  left  ear,  and  again  became  dull  of  external 
hearing,  though  the  sound  of  his  own  voice  Avas  like  thunder.  On 
examination,  the  membrana  tympani  was  observed  to  be  swollen  and 
much  redder  than  natural  ;  its  bloodvessels  being  large  and  dis- 
tended.    "VVatch  heard  at  a  distance  of  two  feet. 

Treatment. — Slight  counter-irritation  was  kept  up  behind  the  ear, 
and  a  cooling  lotion  applied  to  the  meatus  for  ten  days ;  at  the  end 
of  that  time  the  patient  quite  recovered. 

Case  III.  Acute  inflammation  of  the  dermoid  layer  of  the  mem- 
hrana tympani.  Discharge  of  viscid  mucus. — Master  S.,  aged  3, 
was  brought  to  me  by  his  father,  a  physician  in  London,  on  the  19th 
April,  1853. 

History. — A  few  days  previously,  Avlien  not  feeling  very  well,  com- 
plained of  slight  pain  in  each  ear,  which  continued  for  two  days, 
and  was   followed  by  a  discharge  of  mucus,  with  slight  dulness  of 


THE    MEMBRANA    TYMPANI.  1G7 

hearing.      The  latter   symptoms  have  remained  until  the  present 
time. 

On  examination,  each  external  meatus  Avas  ohserved  to  be  par- 
tially filled  ■with  matter,  ■which  "was  removed  by  the  syringe,  and 
found  to  be  composed  of  masses  of  mucus,  similar  in  character  to 
those  issuing  from  the  meatus  in  cases  of  acute  inflammation  of  the 
dermis.  They  Avere  more  flocculent,  whiter,  but  not  so  elongated  as 
in  the  secretion  from  the  mucous  membrane  of  the  tympanum.  After 
the  meatus  had  been  cleansed,  the  outer  surface  of  the  membrana 
tympani  "was  seen  to  be  of  a  deep  red  color,  and  to  project  out"wards 
into  the  cavity  of  the  meatus.  More  minute  inspection  sho"\ved  that 
this  red  appearance  depended  upon  the  tumefaction  of  the  dermoid 
layer  of  the  membrane,  which  being  denuded  of  epidermis,  the  pro- 
cessus brevis  of  the  malleus  ■was  observed  at  its  uppermost  part. 
The  hearing  Avas  very  dull. 

Treatment. — A  leech  Avas  ordered  to  be  applied  to  the  margin  of 
the  orifice  of  each  meatus,  and  hot  poultices  to  be  kept  over  the  ears. 
By  these  means  the  pain  Avas  subdued,  and  the  inflammatory  symp- 
toms abated.  In  the  course  of  three  days  a  small  portion  of  vesica- 
ting paper  Avas  applied  behind  each  ear.  The  poAver  of  hearing  re- 
turned by  degrees,  the  discharge  disappeared,  and  the  dermoid  mem- 
brane regained  its  natural  appearance. 

Case  IV.  Acute  inflammation  of  the  dermoid  layer.  Secretion  of 
mucus. — A.  Moorman,  aged  58,  Avas  admitted  under  my  care  at  the 
St.  George's  and  St.  James's  Dispensary,  on  May  24th,  1850. 

History. — During  the  last  five  months  has  felt  much  debilitated. 
About  seven  Aveeks  previous  to  seeing  me,  pain  suddenly  attacked 
the  right  ear,  and  Avas  folloAved  by  a  "steaming  and  hissing  sound." 
After  this  sound  had  remained  for  three  wrecks,  a  discharge  issued 
from  the  ear,  Avhicli  has  continued  to  the  present  time,  accompanied 
by  a  good  deal  of  itching,  and  by  a  sensation  as  of  something  grind- 
ing within  the  ear.  On  examination,  the  watch  Avas  only  heard  Avhen 
in  contact  with  the  ear  ;  the  dermoid  layer  of  the  membrana  tym- 
pani was  observed  to  be  flat,  red,  and  very  much  swollen  ;  and  there 
was  a  watery  discharge,  consisting  principally  of  epidermoid  cells. 
The  surface  of  the  meatus  was  rather  redder  than  natural. 

Treatment. — The  ear  to  be  syringed  Avith  warm  Avater  twice  daily; 
and  vesicating  paper  to  be  applied  each  night  behind  the  car. 

May  31. — Better  ;  the  noise  less  loud  ;  the  power  of  hearing  in- 
creased. 


168  THE     DISEASES     OF     THE    EAR. 

June  7. — Improves  daily :  the  quantity  of  discharge  is  much 
diminished ;  and  the  noises  have  ceased,  with  the  exception  of  short 
occasional  attacks.  The  membrana  tympani  is  recovering  its  natural 
aspect. 

[b.)    SIMPLE    CHRONIC   INFLAMMATION    OF   THE    DERMOID    LAYER, 
WITH    OR   WITHOUT    AN    ACCUMULATION    OF    EPIDERMIS. 

This  affection  is  also  commonly  produced  by  cold,  but  is  of  little 
importance,  excepting  when  it  results  in  the  secretion  of  large  quan- 
tities of  epidermis.  A  simple  tumefaction  of  the  dermoid  layer 
usually  aflFects  the  hearing  power  too  slightly  to  cause  the  patient  to 
apply  for  relief:  in  many  instances  where  the  layer  has  been  hyper- 
trophied,  the  patients  have  suffered  no  inconvenience.  If,  hoAvever, 
it  becomes  so  tumefied  as  to  render  the  membrana  tympani  tense, 
then  a  perceptible  deafness  is  induced.  In  the  majority  of  cases  of 
hypertrophy  of  the  dermoid  membrane,  there  coexists  a  thickening 
of  the  mucous  membrane  of  the  tympanum,  which  causes  the  deaf- 
ness. The  presence  of  several  layers  of  epidermis  on  the  outside 
of  the  dermis,  is  also  a  source  of  considerable  deafness,  and  very 
frequently  of  uncomfortable  sensations  in  the  ear  and  head. 

Case  I.  Simple  chronic  inflammation  of  the  dermoid  layer,  with 
an  accumulation  of  ej)idcrmis  on  its  surface. — Colonel  T.,  aged  45, 
strong,  and  in  good  health,  consulted  me  on  July  1st,  1855,  on  ac- 
count of  a  buzzing  sensation  in  both  ears,  especially  in  the  right, 
which  had  lasted  for  three  months,  accompanied  by  a  feeling  of  op- 
pression in  the  head  and  dulness  of  hearing.  On  examination,  the 
watch  was  heard  only  when  in  contact  with  the  ear,  and  a  large 
quantity  of  epidermis  was  observed  at  the  bottom  of  the  meatus. 
By  means  of  the  syringe,  several  layers  were  extracted,  and  the 
surface  of  the  dermis,  which  was  red  and  thick,  exposed.  On  the 
removal  of  the  epidermis,  the  noises  and  unpleasant  sensation  in  the 
head  vanished,  and  the  hearing  Avas  much  improved;  the  hearing  dis-' 
tance  Avith  the  Avatch  being  six  inches. 

Case  II.  Clironic  inflammation  and  hypertrophy  of  the  dermoid 
layer. — R.  J.,  Esq.,  aged  25,  visited  me  on  March  20,  1853,  on  ac- 
count of  dulness  of  hearinj;. 

History. — Five  years  ago,  after  a  large  portion  of  cerumen  had 
been  scooped  out,  had  irritation  in  the  ears^  and  remained  deaf  for 
some  time  afterAvards.    Three  months  ago,  when  suffering  from  deaf- 


THE     MEM  BR  AN  A     T  Y  M  P  A  N  I.  1G9 

ness,  was  relieved  bj  the  use  of  the  syringe  ;  lately  the  left  ear  has 
again  become  dull,  and  he  has  complained  of  pain  in  it,  and  in  the 
left  side  of  the  face.  On  examination,  the  right  ear  heard  the 
"watch  at  a  distance  of  two  inches ;  the  left  at  the  distance  of  an 
inch.  The  dermoid  layer  of  each  membrana  tympani  was  hypertro- 
phied,  and  that  of  the  left  ear  was  very  red. 

Treatment. — A  slight  discharge  was  kept  up  from  the  surface  of 
each  mastoid  process,  and  a  weak  solution  of  nitrate  of  silver  (gr.  v. 
ad.  5J)  was  applied  to  the  surface  of  thejiffected  membrane. 

April  9. — Hearing  improved.  The  watch  is  heard  by  the  right 
ear  at  a  distance  of  three  inches  ;  by  the  left,  at  a  distance  of  seven 
inches. 


{c.)    CHRONIC    CATARRHAL    INFLAMMATION    OF    THE    DERMOID    LAYER. 

This  form  of  inflammation  is  far  from  being  rare.  Like  the  same 
disease  of  the  dermoid  layer  of  the  meatus,  it  often  occurs  in  chil- 
dren out  of  health,  and  also  results  from  the  application  of  cold  to 
the  surface  of  the  membrane.  It  very  frequently  takes  its  origin 
in  an  attack  of  acute  inflammation,  which,  instead  of  subsiding,  be- 
comes chronic.  The  discharge  usually  consists  of  the  epidermoid 
cells,  which  are  thrown  off  in  conjunction  with  a  quantity  of  fluid, 
instead  of  forming  a  distinct  epidermoid  layer.  On  removal  of  the 
discharge,  tlie  dermis  is  found  to  be  swollen,  and  entirely  denuded 
of  epidermis  ;  the  color  of  the  surface  varying  from  a  deep  to  a 
palish  red.  The  cases  of  this  disease  require  the  deepest  attention, 
since  they  are  apt  to  terminate  in  the  formation  of  granulations  or 
of  polypi  on  the  surface  of  the  membrane,  or  in  ulceration  ;  the 
latter  process  endangering  the  fibrous  lamina;.  This  affection  is 
also  not  unfrequently  associated  with  a  corresponding  one  of  the 
dermoid  layer  of  the  meatus  ;  which  may  be  subdued  without  the 
disease  of  the  membrana  tympani  being  cured. 

Case  I.  Chronic  catarrhal  inflammation  of  the  dermoid  layer,  with 
thickening  of  the  mucous  membrane  of  the  tympanum. — Rev.  W.  A., 
jBt.  32,  visited  me  on  the  18th  of  November,  1854. 

History. — Since  childhood  the  left  car  has  been  useless.  During 
the  past  year  the  right  car  has  been  dull  of  hearing  at  times,  and 
he  has  complained  of  irritation  of  the  ear,  for  which  he  has  been  in 
the  habit  of  using  an  earpick.     Lately  his  deafness  has  so  increased. 


170  THE     DISEASES    OF    THE     EAR. 

that  he  has  to  be  loudl}'  spoken  to  Avithin  a  yard  of  the  head,  and 
also  complains  of  a  discharge  from  the  right  ear.  On  examination, 
the  dermis  of  the  meatus  in  the  right  ear  was  observed  to  be  red, 
while  the  dermoid  layer  of  the  mcmbrana  tympani  was  partly  red 
and  partly  white :  there  was  also  an  abundant  discharge  of  mucus. 

Treatment. — The  ear  to  be  syringed  out  with  warm  water  thrice 
daily,  three  leeches  to  be  applied  to  the  orifice  of  the  meatus,  and 
vesicating  paper  to  be  kept  behind  the  ear. 

Nov.  2G. — Much  better :  thinks  he  now  hears  as  Avell  as  he  has 
done  for  some  years.  The  dermoid  layer  of  the  membrana  tympani 
is  less  red ;  the  discharge  is  less  abundant. 

Case  II.  Catarrhal  injlammation  of  the  dermoid  layer  after  bath- 
ing.— Miss  J.  G.,  let  27,  consulted  me  on  September  15,  1855,  on 
account  of  a  dulness  of  hearing  in  the  left  car,  Avith  discharge. 

History. — A  year  previously,  immediately  after  bathing  in  the 
sea,  felt  a  slight  pain  in  the  left  ear,  which  continued  for  three  or 
four  days,  and  was  followed  by  a  discharge,  which  has  remained 
until  now,  accompanied  by  a  dulness  of  hearing.  On  examination., 
the  surface  of  the  dermoid  layer  of  the  membrana  tympani  was  found 
to  be  covered  with  discharge,  which  being  removed,  the  membrane 
was  seen  to  be  red,  and  its  bloodvessels  distended.  Under  the 
same  treatment  as  in  the  last  case,  the  patient  was  cured  in  two 
months. 

Case  III.  Catarrhal  inflammation  of  the  dermoid  layer  after 
measles.  Polypoid  groivth  from  the  surface. — Miss  M.  E.  S.,  aged 
10,  not  strong,  Avas  brought  to  me  on  April  2,  1853. 

History. — Three  years  previously  had  an  attack  of  measles,  fol- 
lowed by  discharge  from  the  left  ear,  and  considerable  dulness  of 
hearing  in  both.  Eight  months  ago  had  an  attack  of  low  fever, 
Avhich  remained  for  two  or  three  months,  and  much  increased  the 
deafness.  At  the  present  time  has  to  be  spoken  to  distinctly  within 
a  yard  of  the  right  ear.  Every  night  there  is  discharge,  and  a  cer- 
tain amount  of  earache.      Is  better  in  warm  weather. 

On  examination,  there  was  found  in  the  right  ear  a  large  quantity 
of  discharge,  which  being  removed,  the  dermoid  layer  Avas  observed 
to  be  much  hypertrophicd,  and  red  groAvths  covered  considerable 
portions  of  it,  especially  posteriorly.     Hearing  distance  four  inches. 

Left  ear. — Membrana  tj'mpani  Avhite  at  the  upper  part,  and  the 
dermis  much  thickened;  discharge  abundant:  hearing  distance  half 
an  inch. 


THE     MEM  BR  ANA     TYMPANI. 


171 


Treatment. — A  solution  of  chloride  of  zinc,  two  grains  to  the 
ounce,  -was  injected  into  each  car  daily,  and  a  discharge  was  kept 
up  from  the  surface  of  the  mastoid  process.     Under  this  treatment 


Fig.  fil. 


Granulations  on  the  surface  of  tbe  Dermoid  Layer  of  the  Membrana  Tympani. 
(Seen  through  the  Speculum.) 

the  discharge  disappeared,  and  the  poAver  of  hearing  was  greatly 
improved. 

Case  IV.  Catarrlialinjiammation  of  the  dermoid  layer,  following 
measles. — Master  M.  N.,  aged  6,  pale,  thin,  and  of  a  scrofulous  dia- 
thesis, was  brought  to  me  on  the  12th  of  May,  1851,  on  account  of 
a  discharge  from  the  right  ear. 

History. — Since  infancy  has  been  subject  to  attacks  of  earache  : 
five  montlis  ago  had  an  attack  of  measles,  followed  by  a  discharge 
from  the  right  ear,  which,  though  diminishing  at  times,  has  never 
wholly  ceased.     No  dulness  of  hearing  has  been  perceived. 

On  examination,  the  hearing  distance  of  the  right  ear  was  found 
to  be  reduced  to  four  inches  ;  the  meatus  contained  a  large  quantity 
of  offensive  discharge ;  the  outer  surface  of  the  membrana  tympani 
was  flat ;  the  dermis  was  white,  and  much  thickened. 

Treatment. — Tonic  medicines  were  administered  ;  the  ear  syringed 
out  with  half  a  pint  of  tepid  water  thrice  daily,  and  afterwards  with 
a  solution  of  tannin,  three  grains  to  the  ounce  ;  and  a  stimulating 
liniment  was  rubbed  over  the  mastoid   process  twice  daily.      This 


172  THE     DISEASES     OF     THE     EAR. 

treatment,  persevered  in  for  two  months,  removed  the  discharge, 
diminished  the  hypertrophy  of  the  memhranc,  and  improved  the 
power  of  hearing.  The  patient  was  brought  to  me  three  or  four 
times  subsequently,  suffering  from  a  recurrence  of  the  attack,  but  it 
always  yielded  to  similar  treatment. 


(t7.)    ULCERATION  OF   THE    DERMOID    LAYER    OF    THE    MEMBRANA 

TYMPANI. 

Ulceration  of  the  dermoid  layer  is  an  affection  only  occasionally 
met  with,  and  is  either  the  result  of  long-continued  catarrli  of  the 
dermis,  or  of  the  application  to  its  surface  of  irritating  matters,  or  of 
cerumen.  The  symptoms  are  very  similar  to  those  described  in  the 
previous  section  ;  there  is,  however,  frequently  a  discharge  of  blood, 
and  the  pain  is  more  severe. 

Case  I.  Ulceration  of  the  dermoid  layer  from  the  presence  of  ceru- 
men.— Mrs.  G.,  aged  40,  saw  me  on  May  26th,  1855. 

History. — Fourteen  days  previously  she  had  a  singing  in  the  left 
ear,  which  came  on  suddenly  after  fatigue,  and  has  remained  until 
the  present  period  ;  it  is  accompanied  at  times  with  confusion  in 
the  head. 

On  examination,  the  meatus  was  found  to  be  full  of  cerumen,  and 
the  Avatch  was  only  heard  when  in  contact  with  the  ear.  On  remov- 
ing the  cerumen  by  a  syringe  and  warm  water,  the  outer  surface  of 
the  merabrana  tympani  was  observed  to  be  red.  At  its  anterior 
part  there  Avas  a  small  surface,  about  three-quarters  of  a  line  in  dia- 
meter, Avhere  the  dermis  had  been  wholly  destroyed  by  ulceration  ; 
and  there  was  also  a  small  depression,  at  the  bottom  of  Avhicli  the 
membrane  was  red.  Hearing  distance  reduced  to  eight  inches.  No 
applications  were  made,  and  the  ulcer  healed  in  a  few  days. 

Case  II.  Ulceration  of  the  dermoid  layer ;  fibrous  layers  exposed. 
— J.  A.,  Esq.,  aged  35,  was  sent  to  me  on  March  2G,  1850,  by  Mr. 
Mossop,  of  "Whitehaven. 

History. — Twenty  years  ago,  had  a  polypus  in  the  right  ear,  wliieh 
Avas  removed  ;  but  it  grcAV  again,  and  Avas  a  second  time  removed  ; 
since  the  last  removal  has  had  discharge  at  times  from  this  ear. 
Three  years  previously  had  a  severe  cold,  Avas  very  deaf  for  a  Aveek, 
and  then  gradually  recovered ;  but  since  that  attack  has  been  very 


THE     MEMBRANA     TYMPANI.  173 

(leaf  during  a  cold.  Is  at  present  suffering  from  a  cold,  and  is  so 
deaf  as  to  require  to  be  loudly  spoken  to  close  to  liim. 

Right  ear. — On  examination,  the  surface  appeared  to  be  red,  and 
at  tlie  posterior  part  there  was  a  small  depression,  from  which  the 
dermoid  layer  had  been  eroded  by  ulceration.  Wlien  the  tympanic 
cavity  is  distended,  there  is  an  outward  bulging  of  the  fibrous  layers 
tlirongh  the  orifice  in  the  dermis.  Watcli  heard  Avhen  in  contact 
with  the  ear. 

Left  ear. — Tlie  dermoid  membrane  is  white  and  thick,  and  dis- 
charo;e  issues  from  its  surface.     Ilearino;  distance  half  an  inch. 

Treatment. — A  discharge  was  kept  up  over  each  mastoid  process, 
and  small  doses  of  blue  pill  were  admistered  ;  by  degrees  the  hear- 
ing slightly  improved. 

Case  III.  Ulceration  of  tlie  dermoid  layer.  Discharge  of  blood. — 
M.  S.  Chambers,  aged  7,  was  admitted  under  my  care  at  the  St. 
George's  and  St.  James's  Dispensary,  on  January  18,  1850. 

JTistori/. — A  year  and  a  half  ago,  suffered  from  an  attack  of  small- 
pox, from  which  she  was  very  ill  for  six  Aveeks.  A  few  months  after 
the  attack,  discharge  suddenly  issued  from  both  ears,  and  has  con- 
tinued ever  since,  being  very  offensive,  and  at  times  mixed  with 
blood  :  has  lately  been  also  subject  to  itching  in  the  ears,  earache, 
pains  in  the  forehead,  and  giddiness.  On  examining  the  right  ear, 
its  surface  was  observed  to  be  red  and  tumefied,  and  there  Avas  an 
orifice,  at  the  anterior  part,  through  the  whole  of  the  laminjK. 

Left  ear. — The  dermis  is  of  a  deep  red,  and  its  central  portion  has 
been  destroyed  by  ulceration  :  Avhen  the  tympanic  cavity  is  distended 
Avith  air,  the  fibrous  layers  bulge  outwards. 

The  treatment  consisted  in  the  administration  of  tonics  ;  in  keep- 
ing up  a  discharge  from  the  surfoce  of  the  mastoid  process  ;  and  in 
the  use  of  o;entle  astrin<Tents.  After  several  Aveeks  the  discharge 
gradually  diminished,  and  all  pain  ceased. 

3.  The  fibrous  lamiiue. — Although  the  tAvo  fibrous  lamintxj  arc  so 
distinct  in  their  structure  and  relations,  their  diseases  are  so  similar, 
and  they  are  usually  so  equally  affected,  that  it  is  desirable  to  con- 
sider them  together.  The  diseases  to  Avhich  they  are  liable  are  : — 
Acute  inflammation,  chronic  inflammation,  hypertrophy,  ulceration, 
and  calcareous  defeneration. 


174  THE     DISEASES     OF     THE     EAR. 


(rt.)    ACUTE    INFLAMMATION    OF    THE    FIBROUS    LAMINA. 

"When  the  fibrous  layers  of  the  membrana  tympani  are  the  seat 
of  acute  inflammation,  the  mucous  membrane  of  the  tympanum  is* 
usually  siniihirly  affected,  "whicli  renders  it  difficult  to  define  the 
symptoms  of  acute  inflammation  of  the  fibrous  layers.  This  aff'ec- 
tion  is  usually  excited  by  cold  air  striking  the  outer  surface  of  the 
membrane  ;  hence,  the  suddenly  passing  from  a  heated  room  into 
cold  air,  especially  in  an  easterly  wind,  often  produces  it.  As  in 
inflammation  of  the  mucous  membrane  of  the  tympanum,  there  is 
commonly  the  predisposing  cause  of  debilitated  health.  The  symp- 
toms of  this  aff'ection  are  a  tickling  sensation  deep  in  the  ear,  often 
accompanied  by  involuntary  movements  of  the  membrana  tympani, 
consequent  on  the  irregular  action  of  the  tensor  tympani  muscle. 
This  sensation  increases,  and  a  severe  lancinating  pain  ensues, 
which  is  increased  by  the  act  of  deglutition,  the  use  of  the  hand- 
kerchief, coughing,  or  sneezing.  On  examination,  the  surface  of 
the  membrane  is  seen  to  be  shiny,  its  color  more  leaden  than  usual, 
tinged  frequently  with  a  reddish  hue,  from  the  distention  of  its 
vessels  with  blood.  The  aff'ection  commonly  ends  in  resolution,  but 
sometimes  ulceration  ensues,  which  will  be  afterwards  described. 

The  treatment  of  this  form  of  acute  inflammation  consists  in  the 
use  of  leeches  to  the  margin  of  the  orifice  of  the  meatus,  followed 
by  hot  fomentations  and  poultices  ;  while  calomel  and  opium  are 
administered  internally.  Cases  of  this  disease  will  be  given  under 
"  acute  inflammation  of  the  mucous  membrane  of  the  tympanum." 


{b.)    CHRONIC    INFLAMMATION    AND    HYPERTROPHY    OF    THE 
FIBROUS    LAYERS. 

In  tliis  affection,  the  fibrous  layers  continue  for  some  time  con- 
gested or  become  opaque.  This  disease  will  be  treated  of  at  length 
under  the  head  of  "  rigidity  of  the  membrana  tj'mpani." 


(r.)    ULCERATION    OF    THE    FIBROUS    LAMINvE    OF    THE 
MEMBRANA    TYMPANI. 

This    aff'ection  commonly  originates  either  in   acute  or   chronic 


THE     M  E  M  B  R  A  N  A     T  Y  M  P  A  N  I. 


175 


catarrhal  inflammation  of  the  dermoid  hiyer  ;  but  sometimes  it  is 
the  result  of  primary  acute  inflammation  of  the  fibrous  layers.  It 
usually  occurs  in  persons  of  debilitated  health,  and  is  often  attended 
"with  considerable  constitutional  irritation.  When  it  originates  in 
catarrh  of  tlie  dermoid  layer,  that  membrane  becomes  destroyed  in 
parts,  and  the  outer  surface  of  the  radiate  fibrous  lamina  is  exposed 
to  view.  If  in  this  state  the  mcmbrana  tympani  be  examined  with  a 
speculum  and  a  strong  light,  the  radiate  fibrous  layer  is  seen  to 
form  the  floor  of  a  depression,  the  margins  of  -which  are  formed  by 
the  dermoid  layer.  In  some  cases  this  surface  is  covered  by  deep 
red  granulations  ;  in  others,  large  portions  of  the  fibrous  laminte 
are  exposed,  which  pour  out  an  abundant  discharge  without  the 
presence  of  any  granulations.      After  some  of  the   fibres   of   the 

Fig.  62. 


The  Membrnna  Tympani  fallen  in  towards  the  Promontory,  from  weakness  of  the  fibrous 
lamina).      (Seen  in  section.) 


fibrous  laminae  are  destroyed  by  the  ulcerative  process,  the  remain- 
ing fibres  are  so  much  Aveakened  that  the  whole  lamina  falls  inwards 
towards  the  surface  of  the  promontory,  and  thus  the  size  of  the 
tympanic  cavity  is  greatly  diminished.  In  other  instances,  a  great 
portion  of  the  fibrous  lamina  is  entirely  destroyed,  and  the  mucous 
layer  alone  remains ;  or  portions  of  all  the  laminae  are  eroded,  and  a 
perforation  is  the  result.  Upon  inspection,  a  case  of  perforation  of 
the  mcmbrana  tympani,  produced  by  ulceration  of  the  fibrous  laminae, 
and  advancing  from  without  inwards,  can  always  be  distinguished 
from  a  case  of  perforation  originating,  as  it  more  commonly  does,  in 
catarrh  of  the  mucous  membrane  of  the  tympanum,  and  advancing 


176 


THE     DISEASES     OF     THE     EAK. 


from  within  outwards.  In  the  hitter  chiss  of  cases,  the  margin  of 
the  orifice  is  sharp,  smooth,  and  well  defined  ;  its  shape  is  usually 
round  or  oval ;  and  the  remaining  portion  of  the  membrane,  retain- 


FiG.  63. 


The  Membrana  Tympani  fallen  in  towards  the  Promontorj-,  from  weakness  of  the  fibrous 
lamina\      (Seen  from  without.) 

ing  its  natural  plane,  is  smooth  :  whereas,  in  cases  of  perforation 
from  ulceration  of  the  dermoid  and  fibrous  layers,  the  margins  and 
form  of  the  orifice  are  irregular  ;  and  the  plane  of  the  remnant  of 

Fig.  64. 


An  Orifice  in  the  Membrana  Tj'mpani  produced  bj'  ulceration  of  the  fibrous  lnraina\ 


the  membrane,  deviating  from   the  natural  state,  is   often  funnel- 
shaped,  and  very  concave  externally. 

Ulceration  of  the  fibrous  layers  of  the  membrana  tympani  once 
established  is  liable  to  remain  during  many  years,  and  is  one  of  the 
diseases  hitherto  comprised  under  the  term  "  otorrhoea."  Some- 
times a  large  part  of  the  substance  of  the  fibrous  laj-ers  is  entirely 
effaced,  and  the  outer  surface  of  the  mucous  membrane  pours  out  a 
secretion.  A  singular  accompaniment  of  this  affection  of  the  fibrous 
laminae  is  a  contraction  of  the  carotid  canal.     I  have  so  frequently 


THE     MEM  BR  AN  A     TYMPANI.  177 

found  this  condition  "vvlierc  tlie  menibrana  tympani  has  been  ulce- 
rated, and  so  rarely  met  "with  it  under  other  circumstances,  that  I 
am  induced  to  consider  it  as  connected  with  the  ulceration.  The 
treatment  to  be  pursued  in  cases  of  ulceration  of  the  fibrpus  laminae, 
consists  in  washing  out  the  meatus  frequently  with  warm  water,  and 
in  applying,  by  means  of  a  syringe,  a  weak  solution  of  the  nitrate 
of  silver,  or  some  other  astringent,  to  the  part  affected.  If  the 
membrana  tympani  has  been  perforated,  the  use  of  an  artificial 
membrana  tympani  will  often  be  of  service.  A  slight  discharge 
should  also  be  kept  up  from  the  surface  of  the  mastoid  process. 
Concurrently  with  these  local  aj)plications,  measures  should  be  taken 
to  strengthen  the  general  health. 

Case  I.  Ulceration  of  the  fibrous  lamina>  of  the  mcmhrana  tym- 
pani.— AV.  AV.,  aged  50,  a  medical  man,  residing  in  London,  con- 
sulted me,  in  1852,  on  account  of  a  long-standing  discharge  from 
the  left  ear,  accompanied  by  deafness. 

IHstorij. — In  early  life,  after  repeated  attacks  of  earache,  a  dis- 
charge flowed  from  the  left  ear,  Avhich  has  not  ceased  for  more  than 

Fig.  65. 


The  Fibrous  Layers  of  the  Membrana  Tympani  ulcerated  over  a  small  extent  at  its  anterior 
part.  The  mucous  membrane,  remaining,  forms  a  small  cul-de-sac,  seen  externally. 
This  illustration,  from  a  preparation  in  my  museum,  gives  an  idea  of  the  nature  of  the 
disease. 

a  week  or  two  at  a  time  since  that  period.  Lately  there  has  been 
at  times  great  deafness,  producing  extreme  inconvenience,  as  the 
right  ear  has  been  useless  during  many  years.  L^pon  syringing  the 
left  ear,  a  large  quantity  of  offensive  matter  was  removed,  and  the 
menibrana  tympani  became  distinctly  vi.<ible.  Its  circumference 
was  in  a  natural  state,  but  at  the  central  part  the  dermoid  and 
fibrous  layers  had  been  destroyed  by  ulceration,  so  as  to  disclose 
the  outer  .surface  of  the  mucous  layer.  Instead  of  forming  a  sep- 
tum in  the  situation  of  the  natural  or<]jan,  the  membrane  was  nearly 

12 


178  THE     DISEASES     OF     THE     EAR. 

in  contact  with  the  outer  surface  of  the  promontory.  Upon  the 
patient  swallowing  with  closed  nostrils,  the  mucous  membrane  was 
observed  to  bulge  outwards,  and  form  a  kind  of  bubble,  which  re- 
mained unti.1  the  act  of  swallowing  was  repeated  witli  the  nose  open, 
when  the  membrane  again  fell  inwards.  During  the  time  the  mem- 
brane projected  outwards,  the  hearing  power  was  greatly  improved ; 
but  diminished  as  soon  as  it  fell  inwards. 

The  treatment  consisted  in  syringing  out  the  ear  twice  daily,  so 
as  to  remove  the  discharge,  in  applying  a  weak  solution  of  nitrate 
of  silver  to  the  outer  surface  of  the  membrane,  and  in  keeping  up  a 
slight  counter-irritation  over  the  mastoid  process.  The  result  was, 
that  the  power  of  hearing  improved,  and  the  condition  of  the  mucous 
membrane  became  so  much  strengthened  that,  instead  of  falling  in- 
wards towards  the  promontory,  it  was  able  to  form  a  tympanic  cavity. 
So  long  as  that  remained,  the  hearing  was  excellent ;  but  if  from 
any  cause  the  mucous  membrane  fell  inwards,  the  performance  of 
the  act  of  deglutition,  during  the  closure  of  the  nostrils,  immediately 
restored  it  to  its  natural  position,  and  improved  the  hearing. 

Case  II.  Ulceration  of  the  fibrous  la  mince  of  the  memhrana  tym- 
pani. — Mrs.  E.  C,  aged  38,  consulted  me  in  June,  1850,  on  account 
of  deafness  in  both  ears,  accompanied  by  giddiness  and  discharge. 

History. — Twenty  years  previously  she  had  a  bad  cold,  followed 
by  deafness  and  a  discharge  from  both  ears ;  and  the  latter  has  con- 
tinued to  the  present  time.  Has  been  subject  to  attacks  of  earache, 
usually  followed  by  an  increase  of  the  discharge,  which,  during  a 
cold,  is  much  more  abundant,  often  becoming  very  offensive.  During 
the  last  year  has  been  much  worse,  complaining  of  much  singing  in 
the  head,  and  giddiness.  She  requires  to  be  distinctly  spoken  to 
within  the  distance  of  a  yard.  On  examination,  a  quantity  of  fluid 
discharge  having  been  removed  from  each  meatus,  the  right  mem- 
brana  tynipani  at  the  posterior  and  lower  part  ajipeared  white  and 
thick,  while  the  anterior  and  upper  part  had  fallen  inwards,  and 
appeared  as  if  attached  to  the  promontory ;  its  outer  surface  was 
uneven,  and  poured  out  the  discharge;  air  passed  through  the  Eusta-' 
chian  tube.     Hearing  distance  two  inches. 

Left  ear. — Hearing  distance  one  inch.  The  upper  half  of  the 
memhrana  tympani  had  fallen  inwards,  was  red,  and  poured  out  a 
discharge.  The  treatment  consisted  in  keeping  up  a  discharge  from 
the  back  of  the  neck,  in  syringing  out  the  ears  twice  daily,  and  in 
applying  a  solution  of  nitrate  of  silver  (gr.  xx  ad  oj)  to  the  surface 


THE     MEMBRAXA     TYMPANI. 


179 


of  the  membrane.  Tliis  treatment  was  pursued  during  two  months: 
the  discharge  gradually  disappeared ;  and  the  hearing  was  greatly 
improved. 


(fZ.)    CALCAREOUS    DEGENERATION    OF   THE    FIBROUS   LAMINiB 
OF    THE    MEMBRANA   TYMPANI. 

The  fibrous  laminae  of  the  membrana  tympani  frequently  undergo 
calcareous  degeneration.  This  change  occurs  at  all  periods  of  life; 
sometimes  taking  place  when  the  remaining  portion  of  the  membrane 

Fig.  66. 


Calcareous  Deposit  in  the  Circular  Fibrous  Lamina  of  the  Membrana  Tympani. 

is  healthy,  and  no  other  abnormal  state  can  be  detected  in  the  organ. 
In  some  cases  this  calcareous  condition  of  the  membrane  is  symp- 


FiG.  67. 


Calcareous  Deposit  in  the  ll.i  i...i.  1  .uious  Lamina  of  the  Membrana  Tympani. 

tomatic  of  calcareous  deposit  within  the  tympanic  cavity  ;  in  others, 
it  follows,  and  appears  to  be  produced  by,  chronic  inflammation, 
with  or  without  catarrh  of  the  dermoid  layer.  After  ulceration  and 
destruction  of  portions  of  the  membrane,  the  residue  is  also  at  times 
converted  into  calcareous  matter.  Sometimes  the  calcareous  matter 
is  arranged  in  a  circular  form,  when  it  will  be  found  to  be  deposited 
in  the  circular  fibrous  layer ;  at  other  times  it  assumes   a  radiate 


180  THE     DISEASES    OF    THE     EAE. 

form,  and  tlien  the  radiate  fibrous  layer  is  the  seat  of  the  deposit. 
In  other  cases  the  whole  mass  of  the  membrane  is  converted  into 
calcareous  matter.     Where  there  is  much  diminution  of  the  power 

Fic.  68. 


The  whole  of  the  Membrana  Tyu-j  .i...  .    -ivertetl  into  Calcareous  Matter. 

of  hearing  in  this  disease,  there  is  usually  partial  or  complete  anchy- 
losis of  the  stapes  to  the  fenestra  ovalis,  and  any  treatment  must 
have  for  its  object  the  diminution  of  the  anchylosis.  Patients  ap- 
plying for  relief  in  such  cases  must  therefore  be  treated  by  counter- 
irritation  over  the  mastoid  process,  and  by  the  administration  of 
alteratives. 

Case  I. — M.  C,  aged  32,  consulted  me  in  December,  1854. 

nistory. — When  a  child  he  had  an  attack  of  measles,  followed  by 
great  diminution  of  the  power  of  hearing,  so  that  he  has  ever  since 
been  unable  to  hear  unless  -the  S'peaker's  voice  is  raised  higher  than 
natural,  and  brought  near  to  him.  There  has  been  discharge  for 
many  years  from  the  right  ear.  On  examination,  the  meatus  of  that 
ear  was  found  full  of  thick  discharge  ;  when  this  was  removed  by 
the  syringe,  the  upper  half  of  the  membrana  tympani  was  seen  to 
be  calcareous,  the  lower  half  transparent.  The  Eustachian  tube  was 
pervious.  "Watch  not  heard  when  in  contact  with  the  car  ;  but  the 
crack  of  the  nail  Avas  heard  at  the  distance  of  a  foot. 

Left  ear. — The  anterior  half  of  the  membrana  tympani  was  calca- 
reous ;  Eustachian  tube  pervious  ;  hearing  power  the  same  as  in  the 
opposite  ear.  Gentle  counter-irritation  over  the  mastoid  process  was 
ordered.     The  patient  was  not  seen  a  second  time. 

Case  II.— J.  G.  T.,  Esq.,  aged  18,  consulted  me  in  1855.  The 
general  health  was  good,  with  no  hereditary  tendency  to  deafness. 

History. — Five  years  previously  dulness  of  hearing  slowly  ap- 
peared after  an  attack  of  influenza ;  two  years  subsequently  suffered 
from  scarlet  fever,  followed  by  discharge  from  each  ear,  and  by  a 
great  increase  of  deafness.     The  discharge  has  now  ceased  ;  but 


TUE     MEM  BR  AN  A     TYMPANI.  181 

there  is  so  mucli  deafness  that  he  has  to  be  loudly  spoken  to  within 
three  feet.  At  times,  especially  during  a  cold,  earache  is  com- 
plained of.  On  examining  the  right  ear,  the  watch  was  heard  at 
the  distance  of  half  an  inch.  The  greater  part  of  the  lower  half  of 
the  membrana  tympani  was  converted  into  a  mass  of  crescent-shaped 
calcareous  matter,  but  the  other  part  of  the  membrane  was  healthy. 
Eustachian  tube  pervious. 

Left  car. — Watch  heard  on  pressure  over  the  ear  and  over  the 
temple  ;  the  membrana  tympani  is  more  concave  than  natural ;  and 
there  is  a  patch  of  calcareous  matter,  similar  in  shape  and  size  to 
that  of  the  right  ear.  Eustachian  tube  pervious.  The  same  treat- 
ment was  pursued  as  in  the  last  case,  and  with  some  benefit. 

Case  III. — Mrs.  B.,  aged  34,  in  good  health,  but  subject  to  bilious 
attacks,  consulted  me  in  1854. 

Ilistory. — Since  an  attack  of  earache  when  a  child,  the  left  ear 
has  been  useless.  Three  months  ago  the  right  ear  became  suddenly 
deaf  after  a  cold  ;  the  deafness  was  treated  by  syringing,  the  opera- 
tion being  followed  by  slight  bleeding,  but  no  immediate  improve- 
ment. After  a  few  days,  however,  the  hearing  improved,  but  the 
ear  was  extremely  sensitive,  and  there  was  a  constant  feeling  of  re- 
verberation in  it.  When  more  than  one  person  spoke  at  a  time,  con- 
fusion in  the  ear  was  produced,  and,  during  the  act  of  swallowing,  a 
grating  sound  occurred  in  the  organ.  Noise  like  that  of  a  waterfall 
is  constantly  present  on  the  right  side.  On  examining  the  right 
ear,  the  larger  part  of  the  membrana  tympani  was  found  calcareous  ; 
the  Eustachian  tube  was  pervious ;  the  hearing  distance  was  six 
inches.  The  membrana  tympani  of  the  left  ear  had  so  fallen  in  as 
to  be  in  contact  with  the  promontory.  The  Avatch  was  not  heard, 
but  the  crack  of  the  nail  was  heard  at  a  distance  of  three  inches. 
The  treatment  consisted  in  keeping  up  a  slight  discharge  from  the 
surface  of  the  mastoid  process,  which  Avas  followed  by  great  diminu- 
tion of  the  distressing  noises  in  the  ears. 


{e.)  RELAXATION   OF   THE   FIBROUS    LAMINAE    OF   THE    MEMBRANA 

TYMPANI. 

Some  writers  have  doubted  the  existence  of  the  disease  called 
"  relaxation  of  the  membrana  tympani."     Thus  Dr.  Kramer^  says: 

'  On  the  Diseases  of  the  Ear,  translated  by  Bennett,  p.  143. 


182  THE     DISEASES     OF     THE     EAR. 

"  I  may  be  allowed  to  banish  relaxation  and  tension  of  the  mem- 
brana  tympani  from  the  catalogue  of  diseases  met  with  in  practice, 
in  Avhich  I  have,  indeed,  been  preceded  by  Itard,  who,  however,  has 
not  adduced  his  reasons."  Although  the  writers  who  preceded  Dr. 
Kramer,  who  had  spoken  of  this  disease,  had  not  described  the  symp- 
toms nor  the  appearances  by  which  it  could  be  recognized,  they  were 
nevcfthclcss  correct  in  stating  that  the  disease  in  question  existed. 
Indeed,  it  appears  to  me  that  no  disease  of  the  ear  can  be  more  dis- 
tinctly diagnosed  than  the  one  under  consideration. 

The  causes  of  this  disease  are  : — 1st,  the  effects  of  an  ordinary 
cold,  producing  hypertrophy  of  the  mucous  layer ;  2d,  inflammation 
of  the  fibrous  layers.  From  either  of  these  causes,  the  membrana 
tympani  may  lose  its  natural  degree  of  resiliency  and  become  flaccid 
so  as  to  fall  inwards,  and  approach  more  nearly  to  the  promontory 
than  is  natural :  a  change  which  ends  in  great  dulness  of  hearing. 
This  dulness  may,  however,  be  temporarily  relieved  by  pressing  out 
the  drum  to  its  natural  position,  either  by  swallowing  Avith  closed 
nostrils,  by  attempting  a  forcible  expiration,  or  by  forcibly  and 
rapidly  inhaling  air  through  the  nose.  No  sooner,  however,  is  the 
act  of  swallowing  in  the  natural  way  repeated,  than  the  air  escapes 
from  the  tympanic  cavity,  the  membrana  tympani  falls  inwards,  and 
the  dulness  immediately  returns.  The  treatment  depends  in  a  mea- 
sure upon  the  cause  of  the  affection.  If  the  mucous  membrane 
lining  the  tympanum  be  thickened,  counter-irritation  over  the  mas- 
toid process  should  be  practised  ;  if  the  fibrous  lamin?e  are  inflamed, 
leeches  should  be  applied  to  the  margin  of  the  meatus.  "Where  the 
fibrous  laminne  are  Aveakened,  a  solution  of  the  nitrate  of  silver  ap- 
plied to  the  outer  surface  of  the  membrane  is  frequently  of  great 
service.  There  are  cases  where  the  deafness  is  not  in  the  least  de- 
gree relieved  by  forcing  air  into  the  tympanic  cavity  :  when  this 
happens,  it  is  most  probable  that  partial  anchylosis  of  the  stapes 
has  taken  place.  The  following  cases  illustrate  fully  the  symptoms 
and  treatment  of  this  disease. 

Case  I.  3Iemhrana  tympani  relaxed;  deafness  temporarili/  di- 
minished after  filling  the  tympanic  cavities  with  air. — S.  B.,  Esq., 
aged  18,  consulted  me  in  November,  1853,  on  account  of  dulness  of 
hearing. 

History. — Several  years  previously,  he  became  dull  of  hearing, 


THE     MEMBRANA    TYMPANI.  183 

■vvitliout  pain  or  any  assignable  cause,  and  lately  the  affection  has  so 
much  increased,  that  he  requires  to  be  loudly  spoken  to  Avithin  the 
distance  of  a  yard.  The  deafness  is  greatly  aggravated  during  a 
cold.  The  power  of  hearing  is  much  improved  whenever  he  has 
blown  air  into  each  tympanic  cavity ;  but  as  soon  as  the  act  of  de- 
glutition is  naturally  performed,  a  sensation  of  weight  is  felt  in  the 
ears,  and  the  deafness  returns.  On  examination  of  the  right  ear, 
the  membrana  tympani  was  found  to  be  opaque ;  its  bright  spot 
elongated ;  the  form  more  concave  externally  than  is  natural.  On 
swallowing,  or  forcing  the  air  with  the  nose  closed,  the  membrana 
tympani  expands  to  its  natural  form,  and  remains  so  until  the  act  of 
deglutition  is  repeated  Avith  the  nose  open,  when  it  again  fiills  in- 
wards. Hearing  distance  with  watch,  half  an  inch.  The  left  is  in 
the  same  state  as  the  right  ear.  The  mucous  membrane  of  the 
fauces  is  red  and  thick. 

Treatment. — As  there  was  an  evident  thickening  of  the  membrana 
tympani,  vesicating  paper  was  applied  behind  each  ear ;  the  sixteenth 
of  a  grain  of  bichloride  of  mercury  was  administered  every  night ; 
and  a  lotion  was  applied  to  the  outer  surface  of  each  membrana 
tympani,  consisting  of  three  grains  of  nitrate  of  silver  to  an  ounce 
of  distilled  water.  This  treatment,  at  the  end  of  a  fortnight,  so 
greatly  improved  the  patient's  power  of  hearing,  that  he  could  dis- 
tinctly hear  an  ordinary  voice  at  three  yards'  distance.  This 
improvement  continued  until  the  patient  took  a  severe  cold,  when 
the  deafness  recurred  ;  but  was  subdued  again  by  a  repetition  of  the 
treatment. 

Case  II,  Memlrana  tympani  relaxed  and  coyigested ;  symjjtoms 
diminished  temporarily  hy  a  forcible  inspiration  through  the  nose. — 
J.  J.,  Esq.,  aged  35,  came  to  consult  me  in  September,  1853. 

History. — Since  a  child,  has  been  subject  to  earache  in  each  ear. 
For  a  year  or  two,  this  pain  has  occurred  in  the  right  ear  only,  and 
has  lately  been  very  considerable.  Complains  of  a  feeling  of  rum- 
bling in  the  ears,  and  of  so  great  a  dulness  of  hearing  that  he  has  to 
be  spoken  to  distinctly  within  the  distance  of  a  yard.  The  rumbling 
sensation  and  the  deafness  are  both  temporarily  relieved  by  suddenly 
and  forcibly  drawing  in  the  breath  through  the  nostrils ;  but  this  im- 
provement disappears  immediately  the  act  of  swallowing  is  naturally 
performed,  and  if  that  act  is  delayed,  the  symptoms  slowly  return  in 
in  the  course  of  a  fcAV  minutes.     The  patient  has  thus  acquired  the 


184  THE     DISEASES     OF     THE     EAR. 

habit  of  incessantly  "  sniffing"  the  air,  which  is  exceedingly  unplea- 
sant to  himself  and  to  every  one  around  him.  While  sitting  in  my 
room,  he  must  have  performed  this  act  twenty  or  thirty  times.  On 
examination,  each 'membrana  tympani  Avas  found  red  and  dull,  with 
the  bright  spot  much  larger  than  natural. 

Treatment. — As  there  was  palpable  congestion  of  the  membrana 
tympani,  leeches  were  applied  to  the  margin  of  the  meatus  ;  a  vesi- 
cating paper  kept  on  each  mastoid  process  ;  and  a  warm  solution  of 
chloride  of  zinc  (gr.  ij  @  ^j)  was  dropped  into  each  meatus  twice 
daily.  By  persevering  in  this  plan  of  treatment  for  three  months, 
the  patient  could  hear  nearly  as  well  as  was  natural,  and  had  com- 
pletely lost  the  habit  of  "  sniffing." 

Case  III.  Relaxation  of  memhraTia  tympani  from  thickening  of  the 
tympanic  mucous  membrane,  produced  by  a  cold;  deafness  improved 
by  forcing  air  into  the  tympanum,  and  by  syringing  tvith  water. — 
Miss  J.,  aged  50,  applied  to  me  in  May,  1853. 

History. — Suffered  when  a  child  from  disease  of  the  left  ear,  which 
produced  total  deafness.  For  some  years  the  left  ear  has  been  dull 
during  a  cold,  and  at  times  the  deafness  is  very  great  ;  at  present 
the  patient  has  to  be  spoken  to  loudly  within  the  distance  of  two 
yards ;  but  after  forcing  air  into  the  tympanum,  the  hearing  is  tem- 
porarily so  improved  that  she  can  hear  what  is  said  in  any  part  of 
an  ordinary  sized  room.  This  improvement  can  also  be  produced 
by  syringing  water  ;  but  under  either  treatment,  the  dulness  of  hear- 
ing speedily  returns.  In  order  to  keep  up  a  tolerable  amount  of  hear- 
ing, she  has  fallen  into  the  habit  of  blowing  air  into  the  ear  every 
few  minutes.  On  examination  of  the  right  car,  tlie  hearing  distance 
was  found  to  be  two  inches.  The  membrana  tympani  was  Avhite,  the 
surface  shiny.  Air  entered  through  the  Eustachian  tube,  and  when 
it  distended  the  tympanic  cavity,  the  membrana  tympani  was  seen 
to  move  outwards  to  a  much  greater  extent  than  natural.  This 
movement  was  followed  by  a  great  improvement  in  tlie  hearing, 
which,  however,  very  soon  disappeared. 

Treatment. — Considering  this  to  be  a  case  of  relaxation  of  the 
membrana  tympani,  produced  by  thickening  of  the  tympanic  mucous 
membrane,  slight  counter-irritation  was  excited  over  each  mastoid 
process,  and  a  solution  of  nitrate  of  silver  (gr.  iij  @  oj)  was  dropped 
into  each  ear  every  night.  Tonics  were  administered.  After  this 
treatment  had  been  pursued  for  a  fortnight,  a  manifest  improvement 


THE    MEMBRANA    TYMPANI.  185 

took  place,  the  patient  licard  better,  and  had  no  occasion  to  force 
air  into  the  ear ;  the  habit,  too,  has  been  nearly  overcome.  I  have 
seen  this  patient  once  or  twice  since, — once  during  the  year  1855, — 
and  the  result  of  the  treatment  has,  on  the  whole,  been  satisfactory  ; 
the  hearing  remained  much  better,  except  during  attacks  of  cold, 
when  the  old  habit  of  "clearing  the  ears,"  by  forcing  air  into  them, 
was  had  recourse  to. 


CHAPTER    X. 

THE  MEMBRANA  TYMPAXI  {concluded). 

PERFORATION,  CAUSES — PHYSIOLOGICAL  OBSERVATIONS — EXPERIMENTS  PREVIOUS  TO 
THE  FORMATION  OF  AN  ARTIFICIAL  MEMBRANA  TVMPANI — ON  THE  ARTIFICIAL  MEM- 
BRANA TYMPANI — THE  MODE  OF  APPLYING  IT — CASES — RUPTURE  OP  THE  MEMBRANA 
TVMPANI — PHYSIOLOGICAL    OBSERVATIONS — PATHOLOGICAL    OBSERVATIONS — CASES. 

{a)    PERFORATION    OF    THE    MEMBRANA   TYMPANI,    AND    THE    USE 
OF    THE    ARTIFICIAL    MEMBRANE. 

When  speaking  of  ulceration  of  the  fibrous  layers  of  the  mem- 
brana  tynipani,  I  had  occasion  to  point  out  that  perforation  of  the 
membrane  itself  sometimes,  thougli  rarely,  takes  place  as  a  result. 
The  usual  cause  of  perforation  of  the  raembrana  tympani  is  catarrh 
of  the  tympanic  mucous  membrane.  In  the  latter  case,  a  large 
quantity  of  mucous  is  excreted,  which  fills  the  tympanic  cavity,  and 
being  too  viscid  or  too  abundant  to  escape  through  the  Eustachian 
tube  into  the  fauces,  it  consequently  presses  against  the  inner  sur- 
face of  the  membrana  tympani,  causing  gradual  absorption  of  its 
substance,  and  ultimately  perforation.  That  this  afiection  is  not 
the  result  of  primary  ulceration  of  the  mucous  membrane  lining  the 
inner  part  of  the  membrana  tympani,  is  shown,  I  think,  by  the  fact 
that  in  cases  of  perforation  no  appearances  of  ulceration  are  obser- 
vable in  any  other  parts  of  the  tympanic  cavity  ;  indeed,  as  "will  be 
seen,  Avhen  considering  the  diseases  of  the  mucous  membrane  of  the 
tympanum,  ulceration  is  comparatively  a  rare  occurrence. 

The  most  usual  cause  of  perforation  of  the  membrana  tympani  is 
scarlet  fever:  in  other  cases  it  is  connected  with  scrofulous  disease, 
the  mucous  membrane  of  the  tympanum  throwing  out  large  quan- 
tities of  mucus.  The  result  of  a  perforation  of  the  membrana  tym- 
pani, as  all  medical  men  are  aware,  is  a  certain  diminution  of  the 
hearing  power.     A  small  orifice,  unattended  with  any  other  lesion 


THE     MEM  BR  AX  A     TYMPANI.  187 

of  the  organ,  does  not  produce  such  a  degree  of  deafness  as  to  be 
very  uncomfortable ;  but,  if  in  addition  to  the  small  orifice,  there  is 
a  thickened  and  relaxed  condition  of  the  mucous  membrane  of  the 
tympanum,  or  of  the  remaining  portion  of  the  membrana  tympani, 
then  very  serious  diminution  of  the  hearing  power  occurs.  Even  a 
large  orifice  in  the  membrana  tympani  often  does  not  produce  any 
serious  amount  of  deafness ;  but  if  it  is  accompanied  with  much 
thickening  of  the  mucous  membrane  of  the  tympanum,  the  patient  is 
entirely  debarred  from  conversation,  except  when  specially  addressed, 
in  a  loud  tone,  Avithin  the  distance  of  a  yard.  What  is  the  cause  of 
deafness  in  cases  of  perforation  ?  There  is,  it  seems  to  me,  no  doubt 
but  that  one  of  the  functions  of  the  membrana  tympani  is  to  con- 
fine the  sonorous  undulations  to  the  tympanic  cavity,  in  order  that 
they  may  be  concentrated  on  the  membrana  fenestra)  rotundiie.  In- 
deed, it  is  probable  that  the  vibrations  only  partially  pass  through 
the  chain  of  bones  to  the  vestibule,  and  that  the  air  in  the  tympanic 
cavity  is  one  great  medium  of  communication  Avith  the  labyrinth. 
If  the  means  of  communication  Avith  the  labyrinth  be  the  air  in  the 
tympanic  cavity,  it  is  palpable  that  an  aperture  in  the  membrana 
tympani  is  likely  to  diminish  the  poAver  of  hearing,  by  permitting 
the  vibrations  to  escape  from  that  cavity  into  the  meatus,  and  so 
prevent  their  concentration  upon  the  membrana  fenestras  rotundie. 
This  explanation  of  the  diminished  power  of  hearing  in  cases  of 
perforate  membrana  tympani,  seems  confirmed  by  the  result  of  the 
treatment  adopted  for  their  amelioration. 

Treatment. — Until  very  recently,  the  deafness  arising  from  the 
presence  of  an  aperture  in  the  membrana  tympani  was  regarded  as 
incurable,  and  no  systematic  treatment  Avas  attempted,  although 
several  Avriters  had  alluded  to  the  beneficial  consequences  folloAving 
the  introduction  of  foreign  bodies,  especially  of  lint  and  cotton-Avool, 
Avhere  there  Avas  perforate  membrana  tympani.  Thus  Itard  cites  a 
case  in  Avhich  the  deafness  Avas  completely  relieved  by  introducing  a 
portion  of  cotton-Avool  to  the  bottom  of  the  meatus.  Deleau,  too, 
speaks  of  a  patient  Avho  greatly  improved  his  hearing,  using  in  this 
Avay  a  piece  of  avooI  or  the  central  part  of  an  onion.  Mr.  Todd  de- 
scribes "  the  relief  derived  from  the  mere  introduction  of  a  little  lint 
into  the  external  meatus  in  those  cases  Avhere  the  membrana  tym- 
pani has  been  ruptured  or  destroyed  by  disease.  So  great,  indeed, 
is  the  improvement  Avhich  takes  place  from  the  application  of  this 
simple  remedy,  that  patients  Avill  frequently  appear  astonished  at 


188  THE     DISEASES     OF     THE     EAR. 

being  so  easily  relieved."'  In  the  year  1848,  !Mr.  Yearsley  pub- 
lished a  pamphlet  entitled,  "  On  a  New  Mode  of  Treating  Deafness 
when  attended  by  partial  or  entire  Loss  of  the  Membrana  Tympani, 
associated  or  not  with  Discharge  from  the  Ear."  In  this  pamphlet 
he  advocates  the  application  of  cotton-wool  in  a  moistened  state,  in 
cases  of  partial  or  entire  loss  of  the  membrana  tympani ;  the  object 
of  this  substance  being,  as  he  has  subsequently  stated,  "  to  support 
the  remaining  portion  of  the  membrana  tympani,  or  the  ossicula."^ 
Respecting  the  mode  of  applying  the  wool,  the  following  are  his  in- 
structions :  "A  small  piece  of  wool,  differing  in  size  according  to 
the  case,  and  fully  moistened  in  water,  is  introduced  through  the 
speculum  to  the  bottom  of  the  meatus,  and  adjusted  superiorly,  infe- 
riorly,  anteriorly,  or  posteriorly,  according  to  the  situation  of  the 
perforation  and  other  circumstances  connected  with  the  case  ;  but 
care  must  be  taken  that  the  entire  opening  be  not  covered,  otherwise 
the  experiment  will  not  succeed.  It  is  also  indispensable  to  success 
that  the  moisture  of  the  wool  should  be  preserved." 

After  having  conducted  some  researches  into  the  functions  of  the 
tympanic  cavity,  which  were  laid  before  the  Royal  Society,  and 
made  some  experiments  upon  the  ears  of  patients  suffering  from  per- 
forate membrana  tympani,  it  appeared  to  me  that  an  artificial  mem- 
brana tymjiani  could  be  constructed  which  might  confine  the  vibra- 
tions to  the  tympanic  cavity,  and  concentrate  them  upon  the  laby- 
rinth. The  course  of  investigation  which  has  been  pursued  by  me 
showed  that  the  guttural  orifice  of  the  Eustachian  tube  is  closed, 
except  during  the  momentary  action  of  certain  muscles,  and  that 
for  all  purposes  relating  to  the  passage  of  sonorous  undulations  the 
tympanum  is  a  shut  cavity ;  and  next,  that  by  a  modification  of  Mr. 
Wheatstone's  experiment  with  a  tuning-fork,  suggested  to  me  by 
Mr.  C.  Brooke,  the  sonorous  vibrations  communicated  to  the  bones 
of  the  head  appear  much  louder  when  the  meatus  externus  is  closed 
than  when  the  orifice  is  open. 

If,  for  instance,  a  tuning-fork  be  made  to  vibrate,  and  then  be 
placed  in  contact  with  the  head,  the  sound  proceeding  from  it  will, 
in  a  few  seconds,  cease  to  be  heard ;  but  if  directly  on  this  cessation 
of  sound,  the  experimenter  close  the  entrance  of  the  meatus  in  one 
ear  so  as  to  convert  it  into  a  shut  cavity,  he  will  instantly  hear  a 
renewal  of  the  sound  of  the  tuning-fork  ;  from  which  it  appears 

»  Anatomy  and  Phj-siology  of  the  Organ  of  Hearing.     Pp.  105-6.     1852. 
'  Provincial  Medical  and  Surgical  Journal,  August  18th,  1852. 


THE    MEMBllANA    TYMPANI.  189 

most  prob.ablc  tliat  the  sonorous  A'ibrations  communicated  to  the  ex- 
ternal meatus  impressed  the  niembrana  tympani  much  more  power- 
fully Avlien  confined  "within  the  meatus  than  when  allowed  free  com- 
munication with  the  external  air.  Considering  the  result  of  this 
experiment  in  connection  with  the  other  fact  of  the  ordinarily  closed 
state  of  the  tympanic  cavity,  it  appeared  to  me  highly  probable  that 
the  sonorous  vibrations  imparted  to  the  cavity  of  the  tympanum, 
could  only  make  their  due  impression  on  the  membranes  of  the  laby- 
rinth when  strictly  confined  to  the  tympanic  cavity,  and  not  allowed 
to  expend  themselves  in  the  cavity  of  the  fauces.  This  conclusion 
was  strengthened  by  the  fact,  that  all  the  Avails  of  the  tympanic 
cavity  appear  expressly  constructed  for  producing  resonance,  having 
an  investing  membrane  of  so  great  tenuity  as  scarcely  to  be  detected 
save  by  the  touch  or  the  use  of  a  magnifying  glass,  and  also  by  the 
observation,  that  this  peculiar  condition  of  the  mucous  membrane 
was  restricted  to  the  tympanic  cavity  itself  and  to  that  portion  of 
the  Eustachian  tube  which  forms  part  of  the  resonant  walls  of  that 
cavity. 

If  the  view  here  advanced  be  correct,  and  if  for  the  perfect  per- 
formance of  the  function  of  hearing  it  be  necessary  to  confine  the 
sonorous  vibrations  to  the  tympanic  cavity,  it  is  clear  that  the  ana- 
logy usually  cited  as  existing  between  the  kettle-drum  and  the  tym- 
panum of  the  human  ear,  to  the  eff'ect  that  in  both  the  air  within 
should  be  allowed  to  communicate  with  that  without,  is  incorrect  ; 
and  it  is  further  evident,  that  an  opening  in  the  niembrana  tympani 
must  more  or  less  diminish  the  poAver  of  hearing.  On  examining 
patients  affected  Avith  simple  perforation  of  the  niembrana  tympani, 
the  impaired  inability  to  hear  can,  in  fact,  ahvays  be  detected  ;  al- 
though, as  has  been  stated,  if  the  orifice  be  small  and  the  organ 
otherAvise  healthy,  the  difference  is  but  slight.  In  the  greater  num- 
ber of  cases,  hoAvever,  Avliere  perforation  of  the  membrana  tympani 
exists,  other  lesions  of  a  serious  character  have  coexisted,  such  as 
thickening  of  the  membrane  of  the  tympanum,  pressure  on  the  mem- 
brane of  the  fenestra  rotunda,  derangement  of  the  articulation  of 
the  stapes  with  the  fenestra  ovalis,  or  injury  to  the  nervous  expan- 
sion in  the  labyrinth.  Under  any  of  these  circumstances  it  occurred 
to  me,  that  as  an  orifice  in  the  membrana  tympani,  by  preventing 
the  sonorous  undulations,  OAving  to  their  diff'usion  in  the  meatus, 
from  being  concentrated  upon  the  membranes  of  the  labyrinth, 
might  be  a  direct  cause  of  diminution  of  hearing  poAver,  so  it  Avas 


190  THE     DISEASES     OF     THE     EAK. 

probable  that  increase  of  that  power  wouhl  follow  an  artificial  closing 
of  the  orifice. 

The  preceding  train  of  investigation  led  me  to  attempt  the  con- 
struction of  an  artificial  membrana  tympani,  which,  it  was  hoped, 
might  serve  as  a  substitute  for  the  natural  membrane,  so  far,  at 
least,  as  its  function  of  closing  the  tympanum,  and  thus  rendering 
its  walls  resonant,  was  concerned. 

These  expectations  of  success  Avere  strengthened  by  the  result  of 
observations  made  by  me  on  cases  of  perforate  membrana  tympani. 
When  such  cases  are  not  complicated  with  any  serious  lesion  of  the 
organ,  it  must  have  been  remarked  by  others  as  well  as  by  myself, 
that  the  patient,  from  some  apparently  inexplicable  cause,  at  times 
suddenly  hears  perfectly  well,  or  nearly  so.  This  return  of  the 
hearing  sometimes  remains  for  a  few  minutes  only,  at  others,  for  one 
or  more  hours.  Having  found  the  improvement  to  follow  the  use  of 
a  syringe  and  tepid  water,  or  even  of  the  handkerchief,  I  examined 
the  ear  in  certain  patients  after  these  operations  were  finished,  and 
found  that  in  the  former  case  a  bubble  of  water,  in  the  latter,  of 
discharge,  had  filled  up  the  orifice  in  the  membrana  tympani.  On 
destroying  the  bubble,  the  improvement  in  the  hearing  at  once  dis- 
appeared. In  one  patient  its  stay  could  be  prolonged  by  the  use 
from  time  to  time  of  a  solution  of  gum  acacia  in  water.  On  recon- 
sidering these  facts,  since  the  completion  of  my  observations  upon 
the  closed  state  of  the  tympanic  cavity,  I  have  arrived  at  the  con- 
viction that  the  bubble  of  water,  discharge,  or  mucilage,  acted  bene- 
ficially by  temporarily  reconfining  the  sonorous  imdulations  to  the 
tympanum,  a  conviction  which  subsequent  observations  have 
strengthened. 

After  some  experiments,  I  tried  vulcanized  India-rubber  and 
gutta-percha,  making  use  of  the  thinnest  layers  of  them  that  were 
procurable.  With  both  these  substances,  I  succeeded  in  making  a 
rude  kind  of  artificial  membrana  tympani,  by  cutting  a  portion 
about  the  size  of  the  natural  membrane,  and  passing  through  it  a 
piece  of  thread,  by  means  of  which  it  could  be  conducted  through  a 
fine  tube  to  its  proper  situation.  The  tube  was  then  withdrawn, 
and  the  thread  left  in  the  meatus,  so  that  the  patient,  or  the  ope- 
rator, could  remove  the  artificial  membrane  at  pleasure.  The  dis- 
advantages of  this  apparatus  Avere — difiiculty  of  applying  it  on  the 
part  of  the  patient ;  liability  of  the  material  to  be  torn  by  the 
thread  ;   and  the  unsightliness  of  the  latter  hantring  doAvn  froui  the 


THE     MEMBRANA    TYMPANI.  101 

meatus.  The  experiment,  however,  was  so  far  satisfactory  as  to 
induce  me  to  request  Messrs.  Weiss  to  construct  one,  the  centre  of 
which  should  consist  of  two  very  fine  plates  of  silver,  having  a  dia- 
meter of  about  three-quarters  of  a  line  between  which  the  \njcr  of 
vulcanized  india-rubber,  or  gutta-percha,  might  be  placed,  and 
having  a  silver  wire  attached  to  the  surface  of  the  outermost  plate. 
The  artificial  membrana  tympani,  made  by  Messrs.  Weiss  from 
these  directions,  has  hitherto  been  perfectly  successful.  As  sup- 
plied by  them,  the  portion  of  vulcanized  india-rubber  (the  only  ma- 
terial now  used)  is  about  three-quarters  of  an  inch  in  diameter, 
which  leaves  ample  margin  for  the  surgeon  to  cut  out  a  membrane 
of  any  shape  that  may  seem  to  him  desirable ;  and  to  leave  the 
silver  plate  either  in  the  centre  or  towards  the  circumference  at  his 
discretion.     The  silver  wire  is  of  sufficient  length   to   admit   of  the 

Fig.  69. 


The  Artificial  Membrana  Tyuipani. 


membrane  being  introduced  or  Avithdrawn  by  the  patient,  but  is  not 
perceivable  externally,  except  by  special  observation.     A  pair  of 


Fig.  70. 


Margin  of  the  circumference  of  the  Membrana  Tympani  remaining  after  the  destruction  of 
the  rest  of  the  membrane. 

forceps  is  made,  by  which  the  artificial  membrane  can  be  more  easily 
introduced  or  withdrawn. 


192  THE    DISEASES     OF     THE     EAR. 

Before  describing  the  method  of  applying  the  artificial  membrana 
tympani,  a  few  words  are  required  respecting  the  state  of  the  re- 
maining portion  of  the  membrana  tympani,  after  perforation  has 
taken  place.  The  orifice  is,  in  some  cases,  not  larger  than  a  pin's 
head  ;  in  others,  a  line  in  diameter  ;  Avhile  in  many,  the  entire 
membrane  is  destroyed,  with  the  exception  of  a  margin  at  the  cir- 
cumference, about  half  a  line  in  diameter,  which  being  composed  of 
the  combined  fibres  of  the  thickest  portion  of  the  circular  and  radiate 
laminae,  generally  remains.  This  margin  is  deepest  at  the  upper 
part.  In  rare  cases,  the  long  process  of  the  malleus  continues 
entire,  after  the  complete  destruction  of  the  membrane  to  which 
it  was  attached  ;    but,  as  a  general  rule,  the  whole  of  this  pro- 

FiG.  71. 


Handle  of  the  Malleus  remaining  aftpr  the  destruction  of  the  Membrana  Tympani. 

cess  is  gradually  absorbed,  leaving  merely  the  head  of  the  bone 
(which  articulates  with  the  incus),  the  neck,  and  the  body,  Avhich 
receives  the  attachment  of  the  tensor  t^-mpani  ligament  internally. 
Anteriorly  and  posteriorly  the  fibres  of  the  remnant  of  the  mem- 
brane are  attached  ;  and  externally  tlie  processus  brevis  remains. 
It  will,  therefore,  be  understood,  that  in  cases  of  so-called  destruc- 
tion of  the  membrana  tympani,  a  margin  is  generally  left,  to  which 
the  body  of  the  malleus  remains  fixed,  and  to  the  inner  part  of  this 
the  tensor  tympani  ligament  and  muscle  are  attached  ;  affording  the 
means  by  which  the  small  bones  and  muscles  of  the  tympanum  are 
still  enabled  to  perform  their  functions.  In  cases  of  general  ulce- 
ration of  the  mucous  membrane  of  the  tympanum,  Avhich  fortunately 
seldom  occurs,  the  incus  is  commonly  discharged,  and  sometimes  the 
malleus  also  ;  but  even  in  these  cases,  if  the  attachments  of  the 
stapes  to  the  circumference  of  the  fenestra  ovalis  remain  uninjured, 
the  power  of  hearing  may  be  greatly  improved  ;  should  the  stapes, 
however,  be  removed,  total  and  irremediable  deafness  ensues. 


THE     MEM  BR  AN  A    TYMPANI.  193 

The  artificial  mcmbrana  tympani  is  of  the  greatest  benefit  in  those 
cases  Avhere  there  is  a  Avell-defincd  aperture  in  the  natural  mem- 
brane, or,  if  that  membrane  be  entirely  absent,  Avhere  there   is 

Fir..  72. 


\ 


V 
Body  of  Malleus  remnining  after  destruction  of  Membrana  Tympani. 

simple  hypertrophy  of  the  mucous  membrane  of  the  tympanum, 
with  or  -without  discharge  from  its  surface.  In  these  cases,  the 
organ  Avill  be  found  to  have  by  no  means  entirely  lost  its  power  of 
discerning  sounds  ;  for,  as  a  general  rule,  the  human  voice  is  heard 
when  the  speaker's  mouth  is  brought  within  a  foot  of  the  patient's 
ear,  and  the  speech  is  slow  and  distinct.  This  diminished  poAver  of 
hearing  entirely  excludes  the  sufierer  from  the  advantages  of  gene- 
ral conversation  ;  but  the  deafness  is  greatly  aggravated  when  to 
the  affection  of  the  membrana  tympani  and  mucous  membrane  of 
the  tympanum  is  added  anchylosis  of  the  stapes  to  the  fenestra 
ovalis,  or  when  the  nervous  expansions  have  been  injured.  In  such 
cases,  the  patients  have  to  be  shouted  to  close  to  the  ear,  and  the 
artificial  membrane  is  useless. 


THE    MODE    OF   APPLYING   THE   ARTIFICIAL   MEMBRANA   TYMPANI. 

As  in  cases  of  perforation  or  destruction  of  the  membrana  tym- 
pani, there  is  so  frequently  catarrhal  inflammation  of  mucous  mem- 
brane of  the  tympanum,  it  is  obviously  important  that  no  foreign 
substance  should  be  placed  in  contact  with  that  membrane ;  and  as 
there  is  always  a  margin  of  the  membrana  tympani  remaining,  the 
surgeon  should  be  careful  to  keep  the  artificial  membrane  external 
to  it.     After  accurately  noting  the  size  of  the  inner  extremity  of 

13 


194 


THE     DISEASES     OF     THE     EAR. 


the  meatus  to  which  the  natural  memhrane  was  attached,  the  ope- 
rator should  proceed  to  cut  the  artificial  memhrane  as  nearly  of  the 
size  and  shape  of  the  natural  one  as  possible,  taking  care  at  the 
same  time  to  keep  the  margin  quite  smooth  and  regular.'  The 
patient  should  then  be  placed  with  the  head  inclined  to  the  opposite 
shoulder,  while  a  strong  light  is  thrown  into  the  meatus,  which,  if 
liable  to  discharge,  should  have  been  previously  syringed.  The 
operator  will  next  take  the  artificial  memhrane,  and  having  moist- 
ened it  with  warm  water,  pass  it,  by  means  of  the  silver  wire,  gently 
inwards  until  it  has  reached  what  he  considers  the  natural  position. 
This  he  will  ascertain  by  the  occurrence  of  a  faint  bubbling  sound, 
caused  by  the  escape  of  the  slightly  compressed  air  beyond  it ;  he 


Fig.  73. 


Surgeon  introducing  the  Artificial  Membrana  Tympani. 

will  also  feel  a  slight  obstruction  ofi'ered  to  its  further  passage  by 
the  remnant  of  the  natural  membrane.  Should  any  attempt  be 
made  to  pass  the  artificial  membrane  beyond  this  point,  the  patient 


'  In  cases  where  only  a  small  border  of  the  natural  membrane  remains,  it  is  often  desi- 
rable to  cut  the  artificial  membrane  of  a  size  larger  than  the  inner  extremity  of  the  tube, 
so  that  the  edge  may  turn  outwards. 


THE     MEMBRANA     TYMPANI.  195 

will  complain  of  pain,  -which  up  till  then  had  not  been  felt.  The 
most  certain  test,  however,  of  the  proper  placing  of  the  artificial 
membrane,  is  the  sensation  of  the  patient,  who  discovers,  by  the 
sound  of  his  own  voice,  or  that  of  the  surgeon,  or  by  the  movement 
of  his  tongue  and  lips,  that  his  hearing  has  been  suddenly  improved. 
As  will  be  imagined,  great  care  must  be  taken  to  cut  the  mem- 
brane so  that  it  shall  fit  the  inner  extremity  of  the  meatus  with  ex- 
actness ;  since  if  too  large,  it  would  cause  discomfort,  and  if  too 
small,  it  would  not  fulfil  its  purpose,  of  rendering  the  tympanum  an 
air-tight  cavity.  It  is  not  easy,  in  all  cases,  to  fit  the  artificial  mem- 
brane, so  as  not  to  allow  of  any  communication  between  the  air  in 
the  tympanum,  and  that  in  the  external  meatus  ;  this,  however,  is 
the  object  which  should  always  be  aimed  at.  The  patient,  at  first, 
should  be  told  not  to  use  the  artificial  membrane  for  more  than  two 
hours  daily ;  and  if  any  uncomfortable  feeling  is  experienced,  one 
hour,  or  even  half  an  hour,  will  be  sufficient. 

It  might,  perhaps,  be  expected,  that  the  contact  of  a  foreign  body, 
like  the  artificial  membrana  tympani,  with  the  walls  of  the  external 
meatus,  would  soon  become  intolerable ;  such,  however,  is  not  the 
case ;  several  patients  have  left  my  room  without  being  able  to  say, 
from  the  sensation  in  the  ear,  whether  any  foreign  body  were  there ; 
and  many  have  now  worn  this  apparatus  daily,  during  several  years, 
Avithout  suffering  the  least  pain.  The  explanation  of  this  circum- 
stance may  be  found  in  the  fact,  that  the  most  sensitive  part  of  the 
meatus  cxternus  is  about  its  centre,  while  the  membrane  in  the  im- 
mediate vicinity  of  the  membrana  tympani  is  less  abundantly  fur- 
nished with  nerves :  to  this  may  be  added,  that  the  circumference  of 
the  artificial  membrane  presses  with  extreme  gentleness  against  the 
wall  of  the  meatus. 

The  results  of  the  application  of  the  artificial  membrane  have  been 
more  satisfactory  than  there  was  reason  to  anticipate.  I  have  al- 
ready used  it  beneficially  in  many  hundreds  of  cases.  The  substi- 
tution of  a  thin  layer  of  vulcanized  india-rubber  for  so  exquisitely 
delicate  a  structure  as  the  healthy  membrana  tympani,  would  be 
expected  to  aff'ord  but  trifling  aid ;  yet  such  is  not  the  case ;  for 
among  the  patients  relieved  by  it,  most  have  heard  the  human  voice 
perfectly  across  an  ordinary  sized  room,  and  in  one  case,  the  voices 
of  boys  in  the  open  air,  were  heard  at  a  distance  of  between  one 
and  two  fields.  Surgeons  who  have  paid  careful  attention  to  dis- 
eases of  the  ear,  will  not  be  surprised  at  the  efficient  substitute  the 


196  THE    DISEASES     OF    THE    EAR. 

artificial  membrane  offers,  as  they  "will  call  to  mind  many  cases  in 
■which  the  natural  organ  has  been  greatly  hypertrophied,  especially 
in  chronic  inflammation  of  its  dermoid  layer,  Avitli  but  a  A'ery  slight 
diminution  of  the  power  of  hearing.  ' 

The  surgeon  havino;  ascertained  that  the  artificial  membrane  is 
beneficial  to  the  patient,  it  may  be  allowed  to  remain  in  the  ear  for 
a  few  hours,  and  the  time  gradually  increased  to  a  whole  day.  It 
is  often  desirable,  that  the  use  of  the  membrane  should  be  preceded 
or  accompanied  by  vesication  over  the  mastoid  process,  whereby  the 
thick  mucous  membrane  of  the  t^'mpanum  may  be  rendered  more 
healthy.  In  all  cases,  the  artificial  membrane  should  be  removed  at 
night,  and  when  there  is  any  discharge,  the  ear  should  be  syringed 
night  and  morning  with  tepid  water. 

Case  I.  Deafness  for  sixteen  years ;  discharge  from  each  ear  for 
six  years ;  aperture  in  each  memhrana  tympani ;  power  of  hearing 
restored. — Peter  Turnbull,  aged  43,  formerly  in  the  army,  from 
which  he  was  discharged  on  account  of  deafness,  was  admitted  under 
my  care,  at  St.  Mary's  Hospital,  on  the  12th  January,  1852.  He 
stated  that  sixteen  years  ago,  without  any  other  assignable  cause 
than  a  cold,  he  became  slowly  dull  of  hearing,  and  five  or  six  years 
ago,  a  discharge  issued  from  both  ears,  which  has  continued  to  the 
present  time.  The  power  of  hearing  has  been  gradually  declining, 
so  that  at  present  he  must  be  loudly  addressed  close  to  his  head. 
On  exaynination,  an  aperture,  between  one  and  two  lines  in  diameter, 
was  observed  in  each  memhrana  tympani,  and  the  mucous  membrane 
of  the  tympanum,  which  was  the  source  of  the  discharge,  was  thicker 
and  redder  than  natural. 

The  treatment  consisted  in  keeping  up  counter-irritation  over  each 
mastoid  process,  and  in  the  use  of  an  injection  composed  of  three 
grains  of  acetate  of  zinc  to  an  ounce  of  water ;  and  under  this  he 
somewhat  improved,  though  the  hearing  still  remained  so  defective, 
that  he  was  precluded  from  following  any  avocation.  In  the  com- 
mencement of  June  I  experimented  on  this  patient  with  the  first 
artificial  memhrana  tympani,  composed  of  vulcanized  india-rubber, 
and  the  good  effect  was  at  once  decided.  "When  it  was  placed  over 
the  surface  of  the  original  membrane,  so  as  wholly  to  close  the  ori- 
fice, the  patient  made  a  movement  of  his  lips,  and  said,  "  I  hear  as 
differently  as  possible  from  what  I  have  done  for  many  years  ;  every- 
thing sounds  clear  !"  This  patient  went  away  with  the  artificial 
membrane  in  his  car,  hearing  conversation  perfectly.     The  follow- 


THE    MEMBRANA    TYMPANI.  197 

ing  morning  he  came  to  my  house,  saying,  tliat  he  had  accidentally 
moved  what  I  had  left  in  his  ear,  and  that  "he  was  as  dull  as  ever." 
I  replaced  the  artificial  niemhrane,  and  ho  again  heard  well ;  and 
being  supplied  with  one  which  he  could  introduce  or  remove  at  plea- 
sure, he  has  worn  it  during  the  day  ever  since,  and  lias  never  com- 
plained of  pain  or  discomfort  from  it.  Latterly,  his  hearing  has  so 
greatly  improved,  that  he  has  been  able  to  dispense  Avitli  the  use  of 
the  artificial  membrane  for  a  few  hours  daily,  but  he  hears  much 
better  with  than  without  it.  As  a  proof  of  the  great  amelioration 
that  has  taken  place,  this  patient  told  me,  that  one  day,  while  in  the 
country,  and  using  the  membrane,  he  heard  voices  at  a  distance,  and 
upon  going  to  the  place  whence  they  appeared  to  proceed,  he  found 
some  boys  under  a  hedge,  more  than  a  field  distant  from  the  spot 
where  he  heard  them.     lie  is  going  back  into  the  army. 

This  patient  was  shown  at  a  meeting  of  the  Pathological  Society 
of  London,  in  February,  1853.  The  following  is  the  published  re- 
port : — "  The  artificial  membrane  having  been  removed,  the  mem- 
bers of  the  Society  had  the  opportunity  of  observing  the  perforate 
condition  of  eacli  membrana  tympani.  After  the  removal  of  the 
membranes,  he  could  not  hear,  imless  loudly  spoken  to  ;  but  Avlien 
he  had  replaced  them,  which  he  did  with  apparent  readiness,  his 
hearing  was  excellent." 

Case  II.  Each  memhrana  tympani  destroyed  hy  measles,  at  four 
years  of  age;  hearing  restored  hy  the  artificial  membrane ;. great 
sensibility  to  sounds. — Miss  B.,  aged  21,  consulted  me  on  November 
9,  1853,  on  the  recommendation  of  Dr.  Grindrod,  of  Seaforth,  near 
Liverpool.     The  health  was  good. 

History. — At  four  years  of  age,  she  suffered  from  an  attack  of 
measles,  which  Avas  followed  by  discharge  from  the  ears,  lasting  to 
the  present  time  ;  so  that  the  ears  require  syringing  every  day. 
Since  the  measles,  the  power  of  hearing  so  greatly  deteriorated, 
that  she  has  to  be  distinctly  spoken  to  within  the  distance  of  a 
yard.  On  inspection,  it  was  found  that  the  membrana  tympani  of 
each  ear  had  been  destroyed,  and  that  the  only  vestige  of  it  left 
was  a  very  narrow  margin.  The  mucous  membrane  lining  the  tym- 
panic cavities  was  very  red,  much  thicker  than  natural,  and  covered 
with  a  mucous  discharge. 

Treatment. — An  artificial  membrana  tympani  was  introduced  into 
each  ear,  the  immediate  effect  of  whicli  was  to  improve  the  power  of 
hearing  so  greatly,  that  the  patient  heard  my  voice  perfectly  well 


198  THE     DISEASES     OF     THE     EAR. 

across  my  room  Avith  my  back  towards  her.  Ordered  to  wear  the 
artificial  membranes  during  tlie  day,  to  take  them  out  at  night,  and 
to  syringe  tlie  ears  with  Avarm  water  twice  daily. 

13th. — Has  been  wearing  the  membranes  every  alternate  day,  and 
lias  heard  perfectly  while  they  were  worn ;  indeed,  the  only  drawback 
to  her  comfort  has  been,  that  her  friends  still  speak  loudly  to  her, 
which  causes  considerable  uneasiness  in  the  ears  from  the  very  great 
sound. 

16th. — Continues  to  hear  well ;  but  has  been  obliged  to  remove 
to  a  quiet  street,  as  the  sound  of  carriages  passing  the  house  has 
been  annoying.  She  complains  of  the  "intolerable  rustling  of  her 
silk  dress,"  of  whicli  she  was  never  before  conscious.  The  patient 
left  London  after  some  further  Avatching,  quite  comfortably.  I  re- 
ceived a  letter  from  her  in  the  following  December,  from  Avhich  I 
subjoin  an  extract. 

"  I  am  thankful  to  say,  the  improvement  in  my  hearing  has  in- 
creased almost  daily,  and  I  now  hear  general  conversation  easily, 
and  feel  quite  a  different  person  from  what  I  did  a  short  time  since. 
I  am  still  sensitive  to  sounds,  but  not  nearly  so  much  distressed  with 
them  as  I  was  at  first.  I  found  the  noise  of  the  organ  at  church 
too  great  the  first  time  I  went,  and  came  out  almost  as  soon  as  the 
service  commenced.  I  find  no  pain  in  ni}^'  cars,  and  am,  in  all  re- 
spects, in  the  enjoyment  of  good  health." 

Case  III.  Deafness  of  Uocnty  years'  duration  perfectly  relieved  hy 
the  artificial  membrane. — The  folloAving  particulars  of  a  case,  con- 
cerning which  Ave  corresponded,  Avere  sent  to  me  by  Dr.  Shearman, 
of  Sheffield  : — "  I  tried  the  false  drum  in  one  ear  ;  the  Avhole  of 
the  membrana  tympani  had  been  destroyed,  and  the  caA'ity  of  the 
tympanum  so  bared  to  the  A'icAV,  that  it  was  difficult  at  first  to 
ascertain  Avhether  the  drum  membrane  had  gone,  or  Avas  obscured 
by  polypoid  or  other  groAvths  ;  hoAvever  the  probe  came  doAvn  upon 
the  bone.  The  false  drum  gave  such  relief,  that  the  hearing  dis- 
tance Avas  increased  from  actual  contact  to  tAvelve,  and  subsequently 
to  eighteen  inches  :  the  patient  is  now  able  to  manage  the  contri- 
vance herself. 

"  The  other  membrana  tympani  of  the  same  patient  is  yet  so 
covered  Avith  polypous  groAvths,  that  I  cannot  make  out  the  precise 
condition  of  tlie  drum  ;  hoAvcA'er,  inflation  of  the  tympanum  shows 
that  the  membrana  tympani  is  perforated.  The  deafness  in  this 
case  is  of  nearly  tAventy  years'  duration,  is  perfectly  remoA'cd  on 


THE     MEMBRANA     TYMPANI.  199 

the  left  side,  and  although  the  whole  of  the  left  membrana  tympani 
is  destroyed,  the  false  one  acts  perfectly." 

Case  IV.  Destruction  of  each  membrana  t7/mpani;  stricture  of 
tlie  meatus. — Miss  S.,  hgcd  24,  not  in  very  good  health,  states,  that 
at  four  years  of  age  she  suffered  from  an  attack  of  scarlet  fever, 
subsequently  to  -Nvhich  she  became  so  hard  of  hearing,  as  to  need  to 
be  distinctly  spoken  to  -within  the  distance  of  a  yard.  This  hard- 
ness of  hearing  is  increased  during  cold  and  damp  weather  :  has 
had  discharge  from  both  ears,  but  at  present  it  is  only  very  slight 
from  the  left,  which  is  the  better  ear.  Complains  of  no  pain,  but  of 
a  noise.  Lately,  from  not  being  in  good  health,  the  hearing  has 
been  more  than  usually  dull. 

Examination,  liigld  Ear. — Hearing  distance  of  Avatch,  half  an 
inch.  The  central  part  of  the  meatus  is  contracted  to  less  than  half 
its  natural  size.  A  very  strong  light  having  been  thrown  beyond 
the  contracted  portion,  part  of  the  mucous  membrane  of  the  tympa- 
num could  be  detected  ;  but  there  Avas  no  appearance  of  the  mem- 
brana tympani. 

Left  ear. — Hearing  distance,  one  inch  :  meatus  contracted  as  in 
right  ear  ;  the  membrana  tympani  was  not  seen,  but  in  its  jilace  the 
shining  tympanic  mucous  membrane  Avas  observed. 

At  first  sight  it  appeared  as  if  the  presence  of  the  stricture  Avould 
offer  an  obstacle  to  the  introduction  of  the  artificial  membrane.  I 
nevertheless  tried  a  small  one  to  each  ear,  passing  it  through  the 
stricture,  and  then  moving  it  gently  to  and  fro,  so  as  to  alloAv  it  to 
recover  its  plane  surface.  Having  done  this,  I  moved  it  slightly 
forAvards  to  the  situation  of  the  natural  membrane,  and  immediately 
the  patient  heard  perfectly  all  that  Avas  said  at  any  part  of  the  room. 
There  was  little  difference  between  the  hearing  power  of  the  tAVO  ears. 
Care  was  required  in  the  management  of  the  case,  from  a  slight  ten- 
dency to  irritation  of  the  meatus ;  but  the  patient  left  me  hearing 
Avell.  In  the  middle  of  February,  1854,  the  mother  of  this  lady 
being  in  London,  called  to  thank  me  for  the  benefit  produced  in  her 
daughter's  case.  She  said  that  her  daughter  "  continued  to  hear 
perfectly,  and  that  she  Avas  quite  an  altered  person." 

Case  V.  Deafness  from  scarlet  fever  during  five  years ;  hearing 
completely  restored  by  the  use  of  the  artificial  membrane. — Miss  G., 
aged  14,  was  brought  to  me,  in  August,  1853,  by  Dr.  Grindrod. 
Health  good. 

History. — TVhen  bctAveen  nine  and  ten  years  of  age,  suffered  from 


200  THE     DISEASES    OF    THE     EAR. 

scarlet  fever,  since  wliicli  time,  has  had  a  discharge  from  both  ears, 
attended  by  such  a  decline  of  the  hearing  as  to  require  her  to  be 
loudly  spoken  to  very  near.  She  has  lately  been  to  a  school  at 
Brussels,  ^Yhcre  her  defective  hearing  had  greatly  hindered  her  pro- 
gress. On  inspection,  it  was  found  that  the  mcmbrana  tympani  of 
each  car  was  absent,  Avhile  the  mucous  membrane  of  the  tympanum 
■was  thick  and  red,  and  poured  out  a  mucous  secretion.  An  artifi- 
cial mcmbrana  tympani  was  applied  to  each  ear,  and  produced  so 
complete  a  restoration  of  the  hearing  power,  that  the  patient  could 
detect  all  that  was  said  in  different  parts  of  a  large  room.  This  pa- 
tient returned  to  school  at  Brussels,  and  in  about  six  weeks  after- 
wards, I  received  a  letter  from  the  father,  a  medical  man,  from  wliich 
the  following  is  an  extract : — 

"  We  have  had  the  most  pleasing  intelligence  from  my  little 
daughter  at  Brussels,  respecting  her  hearing.  I  think  I  cannot 
do  better  than  to  give  it  in  her  own  words  : — '  I  have  had  three 
German  doctors,  and  one  French  one,  to  see  me,  or  rather  the  arti- 
ficial membrane.  I  am  quite  a  new  creature,  my  hearing  is  so 
greatly  improved.'  "  The  father  adds,  "  This  is  very  satisfactory 
evidence  as  to  the  successful  operation  of  your  beautiful  invention, 
after  nearly  five  years'  deafness  to  the  extent,  that  she  was  unable 
to  hear  a  w^ord  in  church  the  whole  of  the  time." 

Case  V.  Deafness  for  twcntu  years,  from  measles  and  scarlet  fever, 
greatly  improved  by  the  artijieial  membrane. — Mr.  M.,  aged  23,  con- 
sulted me  20th  December,  1853.     Health  good.     No  relatives  deaf. 

History. — At  three  years  of  age  had  scarlet  fever  and  measles  at 
the  same  time,  accompanied  by  much  discharge  from  each  ear  ;  was 
totally  deaf  for  some  months  after  the  attack,  but  slowly  improved, 
so  as  to  hear  a  loud  voice  spoken  near  the  left  ear ;  the  right  ear 
nearly  useless  ;  lately  has  heard  better  at  times  with  the  left  ear  for 
two  or  three  hours.  To-day  requires  to  be  spoken  to  loudly  within 
two  feet  of  the  left  car,  and  is  about  the  same  as  usual.  On  exami- 
nation of  the  right  ear,  the  meatus  was  found  to  contain  a  collection 
of  mucus  and  epidermis,  Avhich  being  removed  the  mcmbrana  tym- 
pani was  seen  to  be  white  as  paper,  flat  and  thick  :  posterior  to  the 
inferior  third  of  the  malleus  is  a  small  orifice,  al)out  three-quarters 
of  a  line  in  diameter,  through  which  mucus  oozes  from  the  tympanic 
cavity.  "Watch  not  heard  even  when  pressed  against  the  ear  ;  but 
the  crack  of  the  nails  was  distinguishable. 

Left  ear. — The  meatus  contained  a  shreddy  discharge ;  the  mem- 


THE     MEM  BR  AN  A    TYMPANI.  201 

brana  tjmpani  was  absent ;  the  mucous  membrane  of  the  tympanum 
red  and  much  tumefied.  "Watch  heard  when  in  contact  with  the  ear. 
Although  the  hearing  power  of  the  left  ear  was  somewhat  less  than 
in  the  majority  of  cases  where  there  is  an  absence  of  the  membrana 
tympani  uncomplicated  with  any  other  disease,  I,  ncvertlieless,  de- 
termined to  try  the  artificial  membrana  tympani,  the  effect  of  which 
was  to  improve  the  hearing  considerably,  although  not  to  the  same 
extent  as  in  the  majority  of  cases. 

Dec.  21st. — Ordered  to  wear  the  membrane  for  four  hours. 

22d. — Upon  using  the  membrane  to-day,  heard  my  voice  distinctly 
half  across  my  room. 

27th. — Says  that  he  never  remembers  to  have  heard  so  well  as 
yesterday  ;  heard  everything  that  was  said  at  dinner,  and  his  own 
voice  quite  distinctly :  the  sound  of  the  rustling  of  a  lady's  silk 
dress  quite  astonished  him.  Towards  the  latter  part  of  the  day  did 
not  hear  quite  so  well ;  and  last  night,  after  removing  the  drum,  was 
exposed  to  cold,  which  caused  some  pain.  Without  the  drum  to-day 
could  not  hear  my  voice,  unless  I  spoke  in  his  left  ear ;  with  it, 
heard  much  better,  but  not  so  well  as  yesterday,  which  arose  from 
the  mucous  membrane  of  the  tympanum  being  much  tumefied.  This 
tumefaction  gradually  subsided,  and  the  patient  left  me  a  few  days 
afterwards,  hearing  quite  well.  lie  inserts  the  artificial  membrane 
himself,  which  requires  some  care  in  its  adjustment.  On  one  occa- 
sion, when  he  started  for  a  walk  in  the  street,  after  having  inserted 
the  membrane,  his  hearing  was  fitr  from  good  ;  but  as  he  walked  on 
the  pavement,  a  sudden  movement  took  place  in  the  ear,  and  he 
heard  perfectly. 

In  a  letter  of  February,  1854,  this  gentleman  says  :  "  I  have 
much  pleasure  in  informing  you  that  the  artificial  membrane  con- 
tinues to  be  eflFectual ;  my  friends  are  much  gratified  at  the  improve- 
ment you  have  been  able  to  effect." 


(b.)   RUPTURE    OF   THE    MEMBRANA   TYMPANI. 

Previous  to  speaking  of  this  affection,  it  seems  to  me  desirable  to 
make  some  remarks  upon  the  functions  of  the  membrana  tympani 
and  chain  of  ossicles. 

I.  The  Articulation  of  the  Stapes. — The  stapes  is  generally  de- 
scribed by  anatomists  as  being  connected  with   the  margin  of  the 


202  THE     DISEASES     OF    THE    EAR. 

fenestra  ovalis  by  a  simple  membrane.  Sir  Anthony  Carlisle,  in 
his  paper  on  the  Physiology  of  the  Stapes,  merely  speaks  of  "  a 
membrane  which  connects  it  to  the  edges  of  the  fenestra  vestibuli."* 
Professors  Sharpey  and  Quain  agree  -with  Sir  A.  Carlisle.  They 
say,  "  The  annular  ligament  of  the  stapes  connects  the  base  to  the 
margins  of  the  foramen  fenestra  ovalis.  The  fibres  of  the  ligament 
are  covered,  on  the  outer  side  by  the  mucous  lining  of  the  tympanum, 
and  on  the  inner  side  by  the  membrane  of  the  vestibule."'  Mr. 
"Wharton  Jones  describes  this  ligament  as  springing  "from  the  mar- 
gin of  the  vestibular  fenestra,  and  it  is  inserted  into  the  jutting 
margin  of  the  base  of  the  stapes  all  round.'^  Soemmering  seems  to 
have  had  a  diiSerent  view  respecting  this  articulation.  He  says, 
"  A  thin  articular  capsule  connects  the  base  of  the  stapes  to  the 
fenestra  ovalis."^ 

If  the  circumference  of  the  base  of  the  stapes  be  carefully  exa- 
mined by  means  of  a  lens  magnifying  between  three  and  four 
diameters,  it  will  be  apparent  that,  instead  of  a  fine  margin  only,  it 
presents  a  distinct  surface  Avhicli,  when  in  situ,  looks  towards  the 
border  of  the  fenestra  ovalis,  and  is  separated  from  the  inner  and 
outer  faces  of  the  base  by  well-defined  margins.  The  circum- 
ferential surface  of  the  base  varies  in  breadth  :  the  broadest  part 
has  its  surface  inclined  obliquely  backwards  and  outwards  ;  mea- 
sures about  a  third  of  a  line  at  its  centre  ;  and  gradually  narrows 
as  it  becomes  continuous  with  the  superior  and  inferior  surfaces. 
The  anterior  extremity  of  the  surface  is  not  so  broad  as  the  poste- 
rior, and,  instead  of  being  oblique,  is  slightly  rounded.  The  upper 
and  lower  surfaces  of  the  base  of  the  stapes  are  narrower  than  either 
the  anterior  or  posterior  portions,  and  their  middle  part  is  the  nar- 
rowest. AVhen  examined  in  a  recent  ear  the  circumferential 
surface  of  the  base  of  the  stapes  is  found  to  be  quite  smooth, 
and  covered  by  a  very  delicate  layer  of  cartilage,  which,  when 
touched  by  a  fine  probe,  communicates  a  soft  sensation  to  the  finger. 
This  cartilage  consists  of  oval  corpuscles,  very  like  these  in  ordinary 
articular  cartilage,- though  much  smaller,  and  is   most   abundant  at 


•  Philosophical  Transactions,  p.  201.     1805. 
"  Elementary  Anatomy,  p.  940.     1848. 

'  CyclopaHlia  of  Anatomy  and  Phy-siology,  vol.  ii,  p.  548. 

*  De  Corporis  Iliimani  Fabrica,  tomus  .oecundus,  de  Ligamentis  Ossium,  p.  10.  Iluschke 
states,  that  Soemmering  was  wrong  in  regarding  this  ligament  as  a  capsule.  Iluschke 
speaks  of  the  ligamentum  annulare  only. 


THE     MEM  BR  ANA    TYMPANI.  203 

the  two  extremities,  from  -wliich  portions  can  often  be  removed,  es- 
pecially in  young  persons,  for  examination  by  the  microscope.  The 
surface  of  the  fenestra  ovalis  to  which  the  circumferential  base  of 
the  stapes  is  applied,  is  larger  than  that  of  the  stapes  ;  nor  does  its 
posterior  surface  quite  correspond  in  direction  with  that  of  the  stapes, 
but  looks  directly  forwards,  instead  of  obliquely  inwards  and  for- 
wards, to  face  the  stapes,  which,  as  stated,  inclines  backwards  and 
outwards.  The  articulating  surface  of  the  fenestra  ovalis  is  smooth, 
very  compact  in  appearance,  seems  to  have  no  cartilage  upon  it,  and 
is  bounded  by  two  well-defined  ridges.  The  circumference  of  the 
base  of  the  stapes  is  attached  to  that  of  the  fenestra  ovalis  by  means 
of  two  membranes  or  ligaments.  The  inner,  or  vestibular  ligament, 
passes  from  the  inner  margin  of  the  fenestra  ovalis  to  the  inner 
margin  of  the  circumference  of  the  base  of  the  stapes  ;  and  the 
outer  ligament  passes  from  the  outer  margin  of  the  one  to  the  outer 
marffin  of  the  other.  These  two  lio;aments  have  between  them  a 
space  Avliich  may  be  called  the  articular  cavity,  as  it  contains  enough 
fluid  to  lubricate  the  articulating  surfaces  of  the  bones.  By  the 
action  of  the  tensor  tympani  muscle,  the  base  of  the  stapes  is 
pressed  inwards  towards  the  vestibule,  as  a  piston  in  its  cylinder  : 
and  as  soon  as  the  muscle  ceases  to  act,  the  ligaments  just  described 
being  elastic,  draAV  the  base  of  the  stapes  out  again. 

II.  3Iovements  of  the  Stapes. — The  stapes  is  moved  by  two  mus- 
cles, the  tensor  tympani  and  the  stapedius.  Anatomists  seem  agreed 
that  the  action  of  the  tensor  tympani  is  to  press  the  stapes  directly 
inwards  towards  the  cavity  of  the  vestibule,  and  the  general  opinion 
appears  to  be  that  the  stapedius  muscle  merely  assists  the  tensor 
tympani.  Thus  Mr.  "Wharton  Jones  says:  "The  first  action  of  this 
muscle  (the  stapedius)  will  be  to  press  the  posterior  part  of  the  base 
of  the  stapes  against  the  vestibular  fenestra.  At  the  same  time,  the 
long  branch  of  the  incus  will  be  drawn  backwards  and  inwards ;  and 
the  head  of  the  malleus  being,  by  this  movement  of  the  incus,  pressed 
forAvards  and  outwards,  its  handle  w^ill  be  carried  inwards,  and  the 
membrana  tympani  thus  put  on  the  stretch.  Breschet  calls  the 
muscle  of  the  stapes  a  laxator,  but  I  do  not  know  on  what  grounds."* 
Professors  Todd  and  Bowman  Avrite :  "In  contraction  it  (the  stape- 
dius muscle)  would  fix  the  stapes  by  pulling  its  neck  backwards. 
It  probably  compresses  the  contents  of  the  vestibule."^     Ellis  states 

'  Cyclopaedia  of  Anatomy,  vol.  ii,  p.  549. 

"  Physiological  Anatomy,  1847.     Part  III,  p.  71. 


204  THE    DISEASES    OF    THE     EAR. 

that  "it  assists  in  retaining  the  stapes  applied  to  the  fenestra 
ovalis."'  Miillcr  writes  :  "  The  influence  of  the  stapedius  muscle 
in  hearing  is  unknown.  .  .  .  Tlie  onh'  effect  which  it  appears  to  me 
could  be  ascribed  to  it,  would  be  to  render  tense  the  membrane  by 
which  the  base  of  the  stapes  is  connected  with  the  margin  of  the 
fenestra."^ 

On  account  of  the  smallness  of  the  stapedius  muscle,  and  the  very 
slight  degree  of  movement  it  produces,  there  is  difficulty  in  deter- 
mining in  Avhat  way  that  muscle  influences  the  contents  of  the  ves- 
tibule. As  the  tendon  of  the  stapedius,  in  its  course  forwards, 
passes  slightly  upwards,  there  is  good  reason  to  infer  that  it  draws 
the  neck  of  the  stapes  backwards  and  slightly  downwards,  and  that 
it  produces  a  slight  rotation  of  the  base.  That  this  rotatory  move- 
ment of  the  stapes  has  the  effect  of  somewhat  withdrawing  its  base 
from  the  cavity  of  the  vestibule  is,  I  think,  shown  by  the  following 
experiment.  The  tympanic  cavity  and  stapedius  muscle  being  ex- 
posed, and  the  stapes  left  in  situ,  by  means  of  a  small  pair  of  cut- 
ting forceps  a  section  is  to  be  made  through  the  cochlea,  a  portion 
of  which  should  be  left  in  connection  with  the  vestibule.  The  scala 
vestibuli  of  this  portion  will  be  seen  filled  with  fluid  as  far  as  the 
margin  of  the  section ;  and  this  fluid  is  of  course  continuous  with 
the  perilymph  in  the  cavity  of  the  vestibule.  If  the  stapedius  muscle 
be  now  pulled,  or  if  the  neck  of  the  stapes  be  gently  moved  back- 
ward, the  fluid  in  the  exposed  sac  of  the  scala  vestibuli  will  be  ob- 
served to  recede  slightly  into  the  scala  vestibuli,  and  its  surface  to 
become  concave ;  as  soon,  however,  as  the  stapes  is  allowed  to  re- 
turn to  its  quiescent  state,  the  fluid  repasses  into  and  fills  the  scala 
vestibuli,  assuming  a  rounded  surface.  Independently  of  thus  act- 
ing on  the  contents  of  the  vestibule,  the  stapedius  muscle  produces 
a  slight  relaxation  of  the  membrana  tympani.  This  is  effected  by 
the  neck  of  the  stapes,  in  the  act  of  rotation,  passing  outwards  as 
well  as  backwards,  and  thus  gently  pressing  outwards  the  inferior 
extremity  of  the  incus  ;  so  that  the  body  of  the  latter  bone  passes 
inwards,  carrying  with  it  the  head  of  the  malleus,  and  necessitating 
the  long  process  of  the  latter  bone  and  the  membrana  tympani  to 
pass  outwards.  It  would  therefore  appear  that  the  stapedius  muscle 
acts  as  the  direct  antagonist  of  the  tensor  tympani  muscle  ;  the 
former   relaxing    the    labyrinthine    fluid,    the    membrana   fcnestrje 

'  Demonstrations  of  Anatomy,  p.  286. 

'Elements  of  Physiology,  by  Baly,  vol.  ii,  p.  12C4,  1842. 


THE    MEM  BR  AN  A    TYMPANI.  205 

rotundjTO,  and  tlie  menibrana  tympani ;  and  the  latter  rendering 
tense  the  labyrinthine  fluid  and  the  two  membranes.  This  view  is 
supported  by  the  fact  that  the  stapedius  muscle  is  supplied  by  a 
branch  from  the  portio  dura  nerve,  and  the  tensor  tympani  from  the 
otic  ganglion.'  It  seems  to  me  fair,  therefore,  to  infer  that  the 
function  of  the  tensor  tympani  muscle  is  to  protect  the  membrana 
tympani  and  the  labyrinth  from  injury  by  loud  sounds,  while  the 
stapedius  muscle  places  these  structures  in  a  condition  to  be  im- 
pressed by  the  most  delicate  vibrations  ;  and  it  Avould  appear  to  be 
brought  into  action  during  the  process  of  listening.  Instances  are 
not  uncommon  in  which  these  two  muscles  are  unable  to  act  promptly, 
and  the  unpleasant  consequences  are  manifest.  Thus  the  loud  noise 
produced  by  suddenly  and  unexpectedly  firing  a  cannon  near  a  per- 
son, by  not  permitting  the  tensor  tympani  to  contract  in  time,  causes 
frequently  a  sensation  of  singing  or  buzzing  in  the  ears,  produced 
most  probably  by  a  concussion  of  the  expansion  of  the  auditory 
nerve  :  sensations  which  sometimes  endure  for  many  years.  Cases 
are  not  unfrequent  in  which  the  mucous  membrane  of  the  tympanum 
is  thickened,  and  a  great  amount  of  dulness  of  hearing  is  the  conse- 
quence. Many  patients  thus  afiected  hear  sounds  (the  human  voice 
for  instance)  perfectly  well  Avhen  they  are  listening  ;  but  as  soon  as 
the  act  of  volition  is  su.spendcd,  the  same  voice  in  the  same  position 
is  not  perceived.  In  these  cases  it  would  appear  as  if  the  stapedius 
muscle  had  to  counteract  the  pressure  upon  the  stapes,  by  the  thick 
mucous  membrane.     The  friends  of  young  persons  suffering  in  this 

»  In  addition  to  the  above  description,  I  may  draw  attention  to  a  monograpli  on  the  ear 
by  Iluschke,  before  alluded  to,  in  which  he  has  arrived  at  similar  conclusions  respecting 
the  functions  of  the  stapedius  muscle  to  those  just  advanced.  As  it  is  evident,  from  the 
quotations  from  writers  on  the  ear  previously  cited,  that  those  views  have  not  been  enter- 
tained, I  have  not  scrupled  to  give  my  researches  at  length.  The  following  are  lluschke"s 
words:  "While  it  (the  stapedius  muscle)  presses  the  posterior  extreniitj' of  the  base  of 
the  stapes  upon  the  posterior  part  of  the  border  of  the  fenestra  ovalis,  it  lifts  the  anterior 
extremity  of  this  bone  and  covers  the  fenestra.  At  the  same  time,  the  descending  branch 
of  the  incus,  with  the  stapes,  is  drawn  backwards,  by  which  the  body  of  this  bone  presses 
the  malleus  forwards,  and,  as  its  handle  rests  upon  the  membrana  tympani,  it  relaxes  it. 
I  have  often  observed  this  movement  of  the  malleus  when  I  moved  the  long  branch  of  the 
incus  in  the  direction  of  the  tendon  of  the  muscle  of  the  stapes.  I  thus  regard  the  latter 
as  relaxing  the  tympanum  and  opening  the  labj'rinth ;  that  is  to  say,  according  to  the 
view  of  Treviranus,  it  is  the  antagonist  of  the  tensor  tympani  muscles.  The  two  have 
altogether  much  analogy  :  they  describe  an  arch  looking  upwards,  pass  over  a  kind  of 
pulley,  and  are  contained  in  an  osseous  canal ;  but  they  have  also  opposite  functions  :  the 
stapedius  muscle  passes  from  behind  forwards  ;  the  tensor  tympani  from  before  backwards  ; 
the  stapedius  receives  its  nerve  from  the  facial,  the  tensor  tympani  from  the  fifth.' — 
Eiicyclopedie  Aiiatomiqne,  tome  v,  pp.  782,  783. 


206  THE     DISEASES     OF     THE     EAR. 

manner,  often  imagine  that  tliere  is  no  real  duluess  of  hearing,  but 
simply  a  -want  of  attention  ;  the  fact  being  that  the  power  of  hear- 
ing certain  sounds  has  ceased  to  be  involuntary  with  these  patients, 
and  can  only  be  exercised  by  a  strong  effort  of  the  will. 

The  tensor  tynipani  muscle  appears  to  be  of  use  not  merely  in  pre- 
venting the  menibrana  tynipani  and  la])yrinth  from  being  iiijuiod  by 
powerful  sonorous  vibrations,  but  also  in  protecting  these  organs 
from  the  forcible  pressure  of  air  or  of  a  foreign  body.  Tlius  the 
membrana  tynipani  offers  considerable  resistance  to  the  pressure 
of  a  foreign  substance  which  has  been  slowly  introduced  into  the 
meatus ;  though  the  sudden  and  unexpected  contact  of  a  similar 
body  often  produces  extensive  laceration  of  it.  Again,  a  violent 
blow  on  the  ear  with  the  palm  of  the  hand,  rarely  produces  mischief 
to  the  membrana  tympani  when  its  reception  is  expected  ;  whereas 
a  comparatively  gentle  but  unexpected  blow,  frequentl}^  produces 
not  merely  concussion  of  the  nervous  labyrinth  and  serious  derange- 
ment of  its  functions,  but  not  uncommonly  ruptures  the  membrana 
tympani  itself.^ 

The  preceding  observations  indicate  that  one  function  at  least  of 
the  ossicles  and  muscles  of  the  tympanum  and  the  membrana  tym- 
pani, is  to  act  as  the  analogue  of  the  iris  in  tlie  eye,  and  to  regulate 
the  amount  of  sonorous  undulations  that  are  to  pass  to  the  labyrinth. 
This  view  has  already,  to  a  certain  exjent,  been  alluded  to  by  pre- 
vious writers.  M.  Savart,  in  the  course  of  his  very  interesting  re- 
searches upon  the  functions  of  the  membrana  tympani,  arrived  at  a 
somewhat  similar  opinion  ;  although  he  omitted  to  point  out  the 
manner  in  which  the  muscles  acted  on  the  labyrinth  and  membrana 
tympani.  lie  says  :  "  Les  osselcts  out  encore  pour  fonction  de  mo- 
difier Tamplitude  des  excursions  des  parties  vibrantes  des  organes 
contenus  dans  le  labyrinthe."^  Mr.  C.  Brooke,  in  a  Lecture  delivered 
at  the  Royal  Institution,  in  the  year  1843,  says  :  Tliis  osseous  ar- 
rangement may  be  considered  to  perform  an  office  in  the  ear  analo- 
gous to  that  of  the  iris  in  regard  to  light;  namely,  tliat  of  regulating 
the  tension  of  the  various  structures  tliat  are  thrown  into  a  state  of 

'  I  may  mention  a  case  illustrative  of  the  above  statement.  The  first  that  of  an  eminent 
physician  in  London,  who,  while  plajinpj  with  his  children,  received  a  blow  on  one  ear  from 
the  head  of  one  of  them  coming  suddenly  and  rajiidjy  in  contact  with  it :  from  that  time  to 
t,he  present  (an  interval  of  four  to  five  years)  there  has  been  a  constant  ringing  in  that  ear. 

*  Rccherches  sur  les  Usages  de  la  Membrane  du  Tympan  et  de  TOreille  E.\terne  par  M. 
Feli.x  Savart.  Lu  ;\  TAcademie  Royale  des  Sciences,  le  29  Avril,  1S22.  Journal  de  Phy- 
siologic, par  F.  JIajendie,  tome  iv,  p.  183. 


THE    MEM  BR  AN  A     TYMPANI.  207 

vibration,  according  to  the  pitch  and  intensity  of  the  sound  to  be 
transmitted  to  the  sentient  nervous  fibres.  This  is  effected  by  the 
conjoined  action  of  tlie  tensor  tympani  and  stapedius  muscles,  by 
"which  the  tympanum  Avouhl  be  rendered  more  tense,  and  a  simulta- 
neous change  in  the  position  of  the  stapes  -would  alter  the  tension 
of  the  fluid  throughout  the  labyrinth,  and  therefore  also  the  tension 
of  the  membrane  of  the  fenestra  rotunda,  -which  intervenes  bet-\veen 
that  fluid  and  the  air  in  the  tympanic  cavity."^  Professors  Todd 
and  Bowman  state  that  there  is  "  much  reason  to  suppose  that  the 
tensor  tympani  muscle  is  analogous  in  its  use  to  the  iris,  and  des- 
tined to  protect  the  orgafi  from  too  strong  impressions."^ 

The  first  effect  of  the  det^truction  of  the  membrana  tympani  gives 
-weight  to  the  opinion  liere  advocated.  Mr.  Busk  has  detailed  to  me 
the  particulars  of  a  case  in  Avhich,  for  a  few  da^'s  after  the  destruc- 
tion of  the  membrana  tympani,  a  patient  was  unable  to  endure  the 
whistling  of  another  in  an  adjoining  bed  ;  and  Cheselden  says,  "that 
after,  destroying  the  tympanum  in  both  ears  of  a  dog,  for  some  time 
it  received  strong  sounds  with  great  horror."^ 

Pathological  Observations. — There  are  several  modes  in  which  the 
membrana  tympani  may  be  ruptured.  The  most  common  is  an  un- 
expected blow  on  the  ear.  It  may  also  be  ruptured  by  having  a 
foreign  body  forced  through  it  ;  by  very  loud  sounds  ;  by  a  fall ;  by 
violently  blowing  the  nose  ;  or  by  vomiting.  Mr.  Wilde  relates  a 
case  in  which  the  membrana  tympani  was  ruptured  by  a  gentleman, 
while  bathing,  thrusting  his  little  finger  into  the  meatus  to  dislodge 
some  water. 

In  cases  of  simple  rupture,  as  from  an  unexpected  blow  on  the 
ear,  the  margins  of  the  orifice  are  usually  in  contact,  scarcely  any 
hemorrhage  occurs,  fibrin  is  effused,  and  the  rent  is  speedily  re- 
paired. Where,  however,  the  margins  of  the  membrane  are  no 
longer  in  contact,  and  Avhere  the  membrane  has  been  much  strained, 
very  great  irritation  may  ensue,  requiring  active  anti-inflammatory 
measures.  The  most  serious  cases  arise  from  the  injury  inflicted  by 
the  introduction  of  a  foreign  body,  since  the  dermoid  layer  usually 
participates  in  the  disease. 

In  cases  of  simple  rupture  of  the  membrana  tympani  where  in- 
flammatory symptoms  are  still  present,  it  is  not  desirable  to  do  more 
than  introduce  a  portion  of  cotton-wool  into  the  meatus,  to  prevent 

'  Lancet,  1843,  p.  380.  »  Physiological  Anatomy,  Part  III,  p.  91. 

'  The  Anatomy  of  the  Iluman  Body  (5th  edition),  1740,  p.  305. 


208  THE    DISEASES     OF    THE    EAR. 

loud  sounds  from  acting  injuriously  upon  the  drum.  Where  the  in- 
flammation is  great,  leeches  must  be  applied  below  the  ear,  and  to 
the  margin  of  the  orifice  of  the  meatus,  and  evaporating  lotions 
used  to  the  margin  of  the  meatus  itself.  Should  these  remedies  be 
unsuccessful,  counter-irritation  must  be  applied  oyer  the  mastoid 
process. 

Case  I.  Memhrana  tympani  ruptured  hy  an  unexpected  box  on  the 
ear. — Master  G.,  aged  14,  was  brought  to  me  on  June  2,  1852,  on 
account  of  a  peculiar  sensation  in  the  loft  ear  whenever  he  blew  his 
nose. 

History. — Five  days  ago,  as  he  Avas  sitting  still,  his  tutor  came 
quietly  behind  him,  and  suddenly  and  unexpectedly  gave  him  a 
gentle  box  on  the  left  ear,  which  produced  instantaneous  pain  deep 
in  that  organ.  On  using  his  pocket-handkerchief  afterwards,  he  ex- 
perienced a  tingling  and  clicking  in  the  ear,  in  which  he  has  since 
also  had  pain  at  times,  and  from  which  occasionally  a  drop  or  two 
of  blood  have  escaped.      Inspection  showed  a  small  orifice  at  the 

Fig.  74. 


An  Aperture  in  the  lower  part  of  the  left  Membrana  Tympani,  from  rupture. 

lower  part  of  the  membrana  tympani,  about  a  line  in  diameter,  with 
white  borders.  Air  passed  through  on  hohling  the  nose  and  blow- 
ing gently.  The  Avatch  was  heard  at  the  distance  of  a  foot.  As 
there  was  some  slight  pain,  a  leech  was  ordered  to  be  applied  below 
the  ear  every  second  night.  This  Avas  continued  for  ten  days,  at  the 
end  of  Avhich  time  the  pain  had  disappeared,  the  orifice  had  closed, 
and  the  hearing  power  had  returned. 

Case  II.  Rupture  of  the  membrana  tympani  by  a  blotv  on  the  ear 
with  a  bolster. — Master  K.,  aged  14,  Avas  seen  by  me  in  consulta- 
tion with  Mr.  Kcal,  on  December  20,  1855,  on  account  of  an  un- 
pleasant sensation  in  the  left  ear. 

History. — A  Aveck  ago  was  engaged  in  a  "bolstering  match"  at 
school,  during  Avhich  he  received  a  blow  Avitli  a  bolster  on  the  left 
ear,  Avhich  caused  him  pain.     In  the  morning,  on  using  his  pocket- 


THE    MEMBRANA    TYMPANI.  209 

handkerchief,  he  found  that  air  rushed  out  of  the  left  ear,  so  that 
he  was  obliged  to  place  his  finger  upon  the  ear  while  using  the  hand- 
kerchief. On  examining  the  ear,  a  rent  was  observed  in  the  mem- 
brana  tynipani,  running  from  the  lower  extremity  of  the  malleus 
downwards  to  the  inferior  parts  of  the  membrane.  The  margins  of 
the  rent  were  in  contact,  but  the  air  passed  through  with  the 
slightest  pressure  from  the  fauces.  The  hearing  power  was  natu- 
ral. He  was  ordered  a  little  evaporating  lotion  to  apply  on  -cotton 
to  the  orifice  of  the  meatus.  Twelve  days  afterwards,  the  margins 
of  the  orifice  were  observed  to  be  sAvollen,  and  a  small  coagulum  of 
blood  attached  to  them :  air  passed  into  the  tympanum  from  the 
fauces,  but  it  did  not  escape  through  the  aperture.  When  I  saw 
this  patient  after  another  fortnight,  the  orifice  was  closed,  but  the 
cicatrix  remained. 

Case  III.  3Iemhrana  tijmpani  ruptured  by  hloiving  the  nose 
forcibly. — Miss  S.  A.  N.,  aged  16,  consulted  me  on  February  5, 
1850,  for  pain  and  discharge  from  the  right  ear,  accompanied  by 
dulness  of  hearing  in  both  ears.  Her  friends  stated  that  she  had 
for  a  long  time  the  habit  of  blowing  the  nose  A'ery  violently  ;  and 
when  doing  so,  four  or  five  months  ago,  she  felt  as  if  something  had 
given  way  in  the  right  ear,  and  since  that  time  has  had  discharge 

Fig.  75. 


An  Aperture  in  the  posterior  part  of  the  right  Membrana  Tj-mpani,  from  nqiture. 

from  it.  Whenever  the  nose  is  blown,  air  rushes  out  of  the  right 
ear  with  a  loud  S({ueaking  sound.  On  examining  the  right  ear,  the 
membrana  tympani  was  observed  to  be  covered  with  mucus  ;  and 
when  the  nose  was  blown,  air  was  observed  to  issue  from  the  tym- 
panic cavity  through  a  valvular  fissure  at  the  posterior  part  of  the 
membrane.  Watch  heard  at  a  distance  of  two  inches.  The  treat- 
ment consisted  in  applying  leeches  to  the  margin  of  the  meatus,  in 
syringing  out  the  ear  with  a  weak  solution  of  liquor  plumbi  in  water, 
and  in  keeping  up  a  slight  discharge  from  the  surface  of  the  mastoid 
process.     It  was,  however,  only  by  slow  degrees  that  the  discharge 

14 


210  THE     DISEASES    OF    THE    EAR. 

diininisliccl,  ami  the  orifice  in  the  membrane  closed.  The  mem- 
brana  tympani  did  not  regain  its  natural  appearance,  the  part  of  it 
posterior  to  the  malleus  having  fallen  inwards  towards  the  promon- 
tory. 

Case  IV.  Itupture  of  the  memhrana  tympani  hy  a  twig:  injury 
to  chorda  tymjmni  nerve. — J.  L.,  Esq.,  aged  19,  consulted  me  on 
September  25, 1856.  A  week  previously,  while  engaged  in  shooting, 
he  was  endeavoring  to  force  his  way  through  a  hedge,  and  turning 
sharp  round,  with  the  view  of  picking  up  a  bird,  a  twig  passed 
into  the  right  meatus,  producing  a  sudden  and  severe  pain  at  some 
distance  in,  followed  immediately  by  deafness  and  a  little  bleeding, 
which  has  continued  to  a  slight  extent  every  night  since.  A  buz- 
zing noise  in  the  ear  supervened  soon  after  the  accident.  The  pain 
speedily  subsided.  On  examining  the  right  meatus,  a  little  coagu- 
lated blood  was  found ;  on  removing  which  by  the  syringe,  the  mem- 
brana  tympani  presented  a  rupture  extending  through  the  greater 
part  of  its  diameter,  a  little  posterior  to,  and  parallel  with,  the 

Fig.  76. 


An  Aperture  in  the  right  Membrana  Tympani   (a  little  posterior  to,  and  parallel  with,  the 
handle  of  the  Malleus,  nearly  its  whole  length). 

handle  of  the  malleus.  The  edges  of  the  orifice  were  red  and 
swollen.  Air  passed  through  it  when  the  tympanum  was  inflated. 
Watch  only  heard  on  contact.  A  leech  was  applied  to  the  orifice 
of  the  meatus  ;  and  a  mildly  astringent  gargle  applied  gently  by 
the  syringe,  twice  a  day.  On  October  the  4th,  the  orifice  had 
entirely  healed  ;  the  buzzing  noise  had  almost  ceased  ;  the  hearing 
distance  was  half  an  inch.  This  patient  returned  to  India,  but 
intelligence  has  been  received  tliat  the  hearing  has  greatly  im- 
proved. 

For  days  after  the  laceration  of  the  membrane  in  the  above  case, 
there  was  a  feeling  on  the  same  side  of  the  tongue  as  if  something 
cold  had  been  rubbed  over  it ;  the  taste  on  that  side  also  was  im- 
paired. The  tongue,  however,  was  quite  natural  in  appearance  and 
movements,  and  its  sensibility  to  touch  was  the  same  on  both  sides. 


THE     MEMBRAXA     T  Y  M  P  A  N  I.  211 

Case  V,  Rupture  of  the  memhrana  tympani  hi/  the  bursting  of  a 
gun. — W.  S.,  Esq.,  aged  28,  consultcHl  me  in  September,  1856.  Six 
days  ago  was  shooting,  when  the  gun  burst  in  his  hand,  producing 
instant  deafness  in  the  left  ear,  followed,  two  days  ago,  by  a  copious 
discharge  of  a  watery  character.  Yesterday  there  was  a  slight 
aching  pain,  and  for  two  or  three  days  every  pulsation  of  the  vessels 
has  been  heard  in  the  left  ear.  On  examination,  the  left  meatus  was 
found  to  be  red  and  to  contain  purulent  discharge  ;  the  membrana 
tympani  was  also  red,  and  presented  an  aperture  at  its  upper  and 
posterior  part  of  an  oval  shape,  about  a  line  in  length,  and  nearly  a 
line  in  breadth,  as  if  a  portion  of  the  membrane  had  been  destroyed ; 
the  mucous  membrane  of  the  tympanum  was  red,  and  the  hearing 
distance  four  inches.  A  leech  was  applied  occasionally  to  the  mar- 
gin of  the  orifice  of  the  meatus ;  the  car  was  kept  clean  by  daily 
syringing ;  and  afterwards  a  lotion,  the  nitrate  of  silver  (gr.  x.  ad 
5j)  was  applied  on  cotton-wool,  by  means  of  a  probe,  to  the  surface 
of  the  membrane.  The  aperture  slowly  filled  up,  as  if  by  the  de- 
posit of  fibrin  on  the  margins,  which,  for  some  time,  were  thicker 
than  the  surrounding  portion  of  the  membrane  ;  and,  in  the  course 
of  six  weeks,  it  was  entirely  closed,  and  the  hearing  power  perfectly 
restored. 

In  this  case  the  right  membrana  tympani  was  previously  ruptured, 
and  the  bursting  of  the  gun  produced  no  effect  upon  the  ear. 

The  followino;  is  a  tabular  view  of  the  condition  of  the  membrana 
tympani  in  the  dissection  of  1013  diseased  ears : — 

Opaque, 15 

Vascular,          .............  7 

Vascular  and  thick,         ...........  3 

Belaxed,           .............  4 

Tense, 10 

Tense  and  atrophied,       ...........  2 

Inner  surface  connected  to  the  promontory  by  bands  of  membrane,        .         .  32 

Inner  surface  adherent  to  the  incus,         ........  9 

Inner  surface  adherent  to  the  stapes,       ........  4 

Inner  surface  adherent  to  the  stapes,  by  membranous  bands,  .         .         .11 

Inner  surface  adherent  to  the  incus,         .......  .1 

Inner  surface  adherent  to  all  the  ossicles,         .......  2 

Inner  surface  adherent  to  all  the  ossicles  and  the  promontory  by  bands,         .  6 

Outer  surface  more  concave  than  natural,        .......  34 

Outer  surface  more  concave  than  natural,  and  thick,       .          .         .          ■          .  4 

Outer  surface  more  concave  than  natural,  and  opaque.  .....  2 

Outer  surface  more  concave  than  natural,  and  thick  and  opaque,    ...  1 

Outer  surface  more  concave  than  natural,  and  soft,          .....  2 

Outer  surface  more  concave  than  natural,  and  tense,       .....  2 


212 


TUE    DISEASES    OF    THE    EAR. 


Very  concave  externally,  nnd  the  inner  surface  iu  contact  with  the  promon- 
tory  

Very  concave  externally,  and  the  inner  surface  connected  to  tlie  promontory 
by  bands,  ............. 

Very  concave  externally,  and  the  whole  of  the  inner  surface  in  contact  with 
the  inner  wall  of  the  tympanum  ;  the  tympanic  cavity  being  obliterated. 

Very  concave  externally  and  thick,  and  adherent  to  the  promontory. 

Thicker  than  natural,      ..... 

Thick  and  unyielding,      ..... 

Thick  and  white,     ...... 

Thick  and  soft,         - 

Thick  and  tense,  .         .      •   . 

Thick,  nnd  attached  to  the  incus  by  membranous  bands, 

Thick  and  vascular,  nnd  connected  to  the  incus  by  bands, 

Thick  and  opacjue,  ...... 

Thick,  tense,  and  congested,   .... 

Containing  deposits  of  calcareous  matter. 

Containing  spots  of  cartilage. 

Flat,  externally,      ...... 

Flat,  thick,  and  white,    ..... 

Epidermoid  lamina  thick,         .... 

Epidermoid  lamina  absent,      .... 

Dermoid  lamina  very  vascular, 

Dermoid  lamina  very  thick,    .... 

Dermoid  lamina  very  thick  and  vascular, 

Dermoid  lamina  detached  from  the  fibrous  lamina?. 

Radiate  fibrous  lamina  absent,  entirely  destroyed  by  ulceration. 

Radiate  fibrous  lamina  absent  in  parts,  . 

Dermoid  and  fibrous  lamina?  absent  in  parts,  apparently  from 

Radiate  and  circular  fibrous  laminw  destroyed  by  ulceration  in  parts,    . 

Radiate  and  circular  fibrous  lamina)  entirely  destroyed  by  ulceration,    . 

Radiate  and  circular  fibrous  lamina;  entirely  destroyed  by  ulceration  ;  th 
mucous  lamina  being  attached  to  the  promontory,   . 

Radiate  and  circular  fibrous  lamina?  containing  pigment  cells. 

Mucous  lamina  thick,      ........ 

All  the  lamina?  destroyed  by  ulceration  except  the  epidermoid. 

All  the  lamina?  destroyed  by  ulcerntion  exeejjt  the  mucous,    . 

All  the  laminiv  jierforated,       ....... 

All  the  lamina?  absent  apparently  from  ulceration, 

All  the  lamina?  jierforated,  the  remaining  i)ortion  of  the  membrane  being  ad 
herent  to  the  jiromontory, 

All  the  lamina<  perforated,  and  very  thick, 

All  the  lamina'  perforated,  very  thick  and  concave,  and  adherent 
to  the  promontory,   ...... 

All  the  lamina'  jierforated  by  mollu.''cous  tumors,    . 

Upper  part  of  all  the  laminw  detached  from  the  bone, 

The  circular  cartilage  exposed,        .... 


ulcer 


ation, 


internally 


10 

13 

7 
3 

66 
5 

12 
2 
5 
1 
1 
4 
2 

14 
2 
6 
4 
8 
5 
1 
4 
3 
1 
3 
2 
3 
6 
4 


3 
2 
3 
2 
47 
21 


CHAPTER    XL 

THE   EUSTACHIAN   TUBE. 

ANATOMICAL  OBSERVATIONS — PnVSIOLOGICAL  OBSERVATIONS — PATHOLOGICAL  OBSER- 
VATIONS— SEAT  OF  OBSTRUCTION  OP  THE  EUSTACHIAN  TUBE  : — 1.  THE*  FAUCIAL 
ORIFICE.  2.  THE  TYMPANIC  ORIFICE.  3.  MIDDLE  PART. CAUSES  OF  OBSTRUC- 
TION : 1.    THICKENED     MUCOUS     MEMBRANE.       2.    RELAXED     MUCOUS      MEMBRANE. — «, 

OBSTRUCTION    OF    THE    FAUCIAL    ORIFICE    FROM    THICKENED    MDCOUS    MEMBRANE — THE 

EXPLORATION    OF    THE    TUBE THE    OTOSCOPE — TREATMENT — USE  OF    THE  EUSTACHIAN 

CATHETER  AND  OF  THE  EXPLORER — THE  EXCISION  OF  THE  TONSILS — CASES.  b, 
OBSTRUCTION  OF  THE  EUSTACHIAN  TUBE  AT  ITS  FAUCIAL  ORIFICE  FROM  RELAXED 
MUCOUS  MEMBRANE — SYMPTOMS TREATMENT — CASES.  C,  OBSTRUCTION  OF  THE  EUS- 
TACHIAN TUBE    AT    THE    TYMPANIC    ORIFICE     FROM     THICKENED    MUCOUS     MEMBRANE — 

SYMPTOMS — TREATMENT ON    THE    OPERATION    OF    PUNCTURING    THE    MEMBRANA    TYM- 

PAXI.  d,  OBSTRUCTION  OP  THE  MIDDLE  PART  OF  THE  EUSTACHIAN  TUBE  BY  MUCUS, 
BY    STRICTURE,    OR    BY    MEMBRANOUS    BANDS. 

Anatomical  Observations. — The  Eustachian  tube,  extending  be- 
tween the  cavity  of  tlie  fauces  and  that  of  the  tympanum,  is  from  an 
inch  and  a  half  to  two  inches  in  length.  At  its  faucial  orifice  it  is 
wide  and  dilatable,  but  it  soon  becomes  so  constricted  as  barely  to 
admit  an  ordinary-sized  probe.  Its  direction  from  the  tympanum 
is  obliquely  downwards,  inwards,  and  forwards. 

The  Eustachian  tube  consists  of  two  portions,  the  osseous  and 
fihro-cartilaginous :  the  osseous  portion  extends  from  the  tympanic 
cavity  to  the  fibro-cartilaginous  portion ;  and  is  about  three-quarters 
of  an  inch  in  length,  and  about  a  line  in  diameter.  It  is  lined  by 
an  extremely  thin  fibro-mucous  membrane,  very  similar  to  that 
lining  the  tympanic  cavity. 

The  fibro-cartilaginous  portion,  as  its  name  implies,  consists  of 
cartila";e  and  fibrous  tissue,  and  is  about  an  inch  in  lenfrth.  It  is 
of  a  conical  form,  having  its  apex  continuous  with  the  osseous  por- 
tion, while  the  base  extends  into  the  cavity  of  the  fauces  in  the 
shape  of  a  rounded  tubercle.  On  examination,  the  rounded  extre- 
mity of  the  cartilaginous  portion  is  found  to  form  a  superior  and 


214  THE     DISEASES     OF     THE     EAR. 

inferior  lip  :  the  former  projects  sliglitly  (loAvnAvartls,  and  forms  the 
the  upper  wall  or  angle  of  the  tube  ;  the  latter  turns  slightly  up- 
wards, and  forms  the  inferior  angle.  The  fibrous  membrane  form- 
ing the  outer  wall  of  the  tube  is  attached,  above  and  below,  to  the 
two  lips  just  described;  forming  anteriorly  a  free  boixler,  and  poste- 
riorly being  attached  to  the  anterior  border  of  the  outer  part  of  the 
osseous  portion.  The  trumpet-shaped  fiiucial  orifice  of  the  Eusta- 
chian tube  is  nearly  half  an  inch  long  ;  and  its  middle  part  may  be 
considered  to  be  on  a  level  with  the  inferior  meatus  of  the  nose. 

The  use  of  the  Eustachian  tube  is  to  allow  ingress  of  air  to  the 
tympanum,  and  egress  of  mucus  from  it  ;  but  the  point  of  import- 
ance which  specially  claims  attention  is,  whether  its  guttural  orifice 
remains  always  open,  so  that  the  air  in  the  cavity  of  the  tympanum 
is  constantly  continuous  Avith  that  in  the  fauces.  The  opinion  of 
physiologists  is  in  favor  of  this  view.  Muller  says,  that  the  object 
of  its  being  constantly  open  is,  "  that  a  certain  degree  of  dulness 
which  the  sound  might  acquire  from  the  resonance  of  the  apparatus 
is  avoided  :"  and  adds  that,  "  Henle  supposes  that  the  air  of  the 
cavity  of  the  mouth  and  nose  are  in  like  manner  evolved  through 
the  medium  of  the  Eustachian  tube,  to  increase  by  resonance  the 
intensity  of  sounds  entering  the  ear  by  the  external  meatus."* 

Dr.  Todd  speaks  of  one  object  of  the  Eustachian  tube  being  to 
"  afford  an  outlet  for  the  escape  of  such  sonorous  undulations  as  do 
not  impinge  upon  the  labyrinthine  Avail  of  the  tympanum."^ 

Other  writers  differ  in  some  measure  from  the  foregoing  view, 
and  some  physiologists  are  not  in  favor  of  the  constantly  patent 
condition  of  the  Eustachian  tube.  Thus  Mr.  Wharton  Jones  says, 
"  It  is  to  be  remarked  that  the  Eustachian  tube  is  not  habitually 
wide  open,  so  that  the  air  can  flow  freely  in  and  out,  but  that, 
on  the  contrary,  in  the  state  of  rest  its  walls  are  collapsed.  By 
this  arrangement,  Avhich  gives  the  Eustachian  tube  the  property 
of  a  Aveak  valve,  opening  either  Avay,  the  too  ready  course  of  the 
air  is  opposed."^ 

Ilyrtl  agrees  in  the  above  statement,  and  saA's,  "  The  Avails  of 
the  convoluted  trumpet  are  disposed  to  lie  upon  each  other  and 
form  mucous  adhesions,  so  that,  as  any  one  can  easily  satisfy 
himself,  a  considerable   degree  of  compression  of   the   air  in    the 

'  Mullen's  Physiology,  translated  by  Baly,  vol.  ii,  pp.  1270-1273. 

'  Cyclopaedia  of  Anatomy  and  Physiology,  article  "  Hearing,"  p.  576. 

'  Cyclopaedia  of  Surgery,  p.  23.     1841. 


THE    EUSTACniAN    TUBE.  215 

mouth  and  nose  (by  means  of  the  muscles  of  the  cheek,  the  mouth 
being  shut)  is  necessary  to  force  air  into  the  cavitas  tympani."^ 

In  a  paper  laid  before  the  Royal  Society,  in  1853,  I  endeavored 
to  show  that,  in  the  state  of  repose,  the  faucial  orifice  is  always 
shut ;  that  the  means  by  which  it  is  opened  are  the  muscles  of  the 
palate;  and  that  it  is  opened  during  the  act  of  deglutition.  In 
that  paper  it  was  further  pointed  out,  that  in  man  and  in  most 
mammalia,  the  muscles  opening  the  Eustachian  tube  were  tlie  tensor 
and  levator  palati,  which  have  been  long  known  to  be  attached  to 
its  orifice.  In  some  mammalia  the  tube  is  opened  by  the  superior 
constrictor  of  the  pharynx,  and  in  birds  by  the  internal  pterygoid 
muscles.  That  the  Eustachian  tube  is  usually  shut,  and  the  act 
of  swallowing  is  the  process  whereby  it  is  opened,  is  shown  by  the 
following  experiments  : — If  the  cavity  of  the  tympanum  be  par- 
tially distended  with  air,  by  making  an  attempt  at  a  forcible 
expiration  through  the  nose  when  the  nostrils  are  held  closed,  a 
sensation  of  fulness  or  pressure  is  experienced  in  the  tympanum, 
arising  from  the  pressure  of  the  air  against  the  inner  surface  of 
the  membrana  tympani :  a  sensation,  however,  Avhich  does  not  dis- 
appear as  soon  as  ordinary  respiration  is  carried  on,  but  remains 
until  the  act  of  swallowing  is  performed,  and  the  air  thereby 
allowed  to  escape.  Again,  if  the  mouth  and  nose  be  held  closed 
during  the  act  of  deglutition,  the  same  sensation  of  pressure  in  the 
ears  is  felt :  for  during  that  act  the  air,  which  is  slightly  com- 
pressed by  the  muscles  of  the  fauces,  passes  into  the  tympanic 
cavities  ;  as  in  the  former  experiment,  the  feeling  of  distention  is 
not  relieved  until  the  act  of  swallowing  is  repeated  Avith  the  mouth 
and  nostrils  open.  A  third  example,  proving  the  Eustachian  tubes 
to  be  opened  during  the  act  of  deglutition,  and  closed  when  the 
muscles  of  the  fauces  return  to  a  quiescent  state,  is  alForded  by  a 
person  descending  in  a  diving-bell.  It  is  well  known  that  during 
the  descent  the  compressed  air  filling  the  external  meatus  produces 
a  sensation  of  weight,  and  often  of  pain,  by  pressing  the  membrana 
tympani  inwards.  This  sensation  can,  however,  be  at  onced  eased 
by  an  act  of  swallowing,  whereby  the  condensed  air  is  allowed  to 
enter  the  tympanum  through  the  Eustachian  tubes,  and  thus  afford 
support  to  the  inner  surface  of  the  membrane.  A  further  proof 
that  air  enters    the   tympanic    cavity  during   deglutition  with  the 

*  Vergleichende  Anatomie  uber  das  innere  Gehororgan  des  Menschen  und  der  Saug- 
thiere,  1845,  p.  51. 


216  THE    DISEASES    OF    THE    EAR. 

nostrils  closed,  and  passes  out  again  during  the  same  act  with  the 
nostrils  open,  is  obtained  by  the  inspection  of  the  membrana  tym- 
paiii  in  the  living  person,  by  means  of  a  strong  light,  during  the 
two  operations  :  in  many  instances,  the  membrana  tympani  is  seen 
to  be  pressed  slightly  outwards  by  the  first  act,  and  to  return  to 
its  previous  state  during  the  second. 


ON   THE    MUSCLES   "WHICH    OPEN   THE    EUSTACHIAN    TUBE. 

Valsalva,^  in  his  admirable  treatise  on  the  human  ear,  appears  to 
have  been  the  first  anatomist  who  pointed  out  the  fact,  that  the 
tensor  and  levator  palati  muscles  take  an  origin  from  the  Eusta- 
chian tube  ;  he  also  gave  them  the  appellation  of  the  muscles  of  the 
Eustachian  tube ;  but  he  considered  that  their  function  is  to  keep 
the  tube  constantly  open,  as  he  believed  that  "  if  the  tube  is  closed, 
the  hearing  is  lost  at  once." 

Most  modern  anatomists  have  described  the  muscles  of  the  soft 
palate  as  taking  their  origin  from  the  Eustachian  tube  ;  but  they 
have  not  ascribed  to  them  the  function  of  opening  or  of  otherwise 
aflfecting  the  tube. 

As  stated,  the  two  muscles  which  open  the  tube  in  man  are  the 
tensor  and  levator  palati. 

The  tensor  2>a^(tti  muscle  arises  from  the  fossa  at  the  root  of  the 
internal  pterygoid  plate,  from  the  adjacent  bone,  from  the  outer  sur- 
face of  the  superior  cartilaginous  lip  of  the  Eustachian  tube,  and 
from  the  membrane  forming  its  outer  wall  ;  and  the  fil)rcs  from 
these  several  sources  pass  downwards,  form  a  flat  muscle  Avhich 
winds  round  the  hamular  process  of  the  sphenoid  bone,  to  be  in- 
serted into  the  aponeurosis  of  the  palate,  and  into  the  ridge  of  the 
palate  bone. 

The  levator  jjalati  muscle  arises  from  the  inferior  surface  of  the 
petrous  bone,  near  the  apex,  and  from  the  outer  half  of  the  under 
surface  of  the  cartilaginous  portion  of  the  tube  ;  and  the  fibres  de- 
scend in  contact  with  the  inner  half  of  the  under  surface  of  the  tube, 
and  are  inserted  into  the  aponeurosis  of  the  palate,  some  of  the  fibres 
uniting  with  those  on  the  opposite  side. 

The  action  of  the  tensor  palati  muscle,  when  it  contracts,  is  to 
draw  slightly  outwards,  and  to  keep  on  the  stretch,  the  membrane 

'  De  Aure  Humana  Trnetatus,  1735. 


THE     EUSTACHIAN     TUBE.  217 

forming  the  outer  wall  of  the  Eustachian  tube ;  the  action  of  the  leva- 
tor palati  muscle  is  to  draw  downwards  and  keep  tense  the  lower 
wall  of  the  tube :  hence  it  will  be  seen  that  the  combined  action  of 
the  two  muscles  is  to  keep  open  the  tube  by  drawing  the  membrane 
forming  its  outer  wall  apart  from  the  cartilage  forming  its  inner 
wall. 

As  during  the  act  of  deglutition  the  tensor  and  levator  palati 
muscles  contract,  it  is  evident  that  whenever  that  act  is  performed, 
the  Eustachian  tube  must  be  opened  ;  and  inasmuch  as  there  is  no 
apparatus  by  which  the  faucial  orifice  of  the  tube  can  be  kept  open, 
its  lips  must  fall  together,  and  the  orifice  close  as  soon  as  the  muscles 
cease  their  action.  During  the  few  moments  that  the  faucial  muscles 
are  brought  into  play  in  the  process  of  deglutition,  air  can  either 
enter  or  recede  from  the  tympanic  cavity,  and  thus  be  always  of  the 
same  density  as  the  outer  air.  The  reasons  why  the  Eustachian 
tube  is  closed,  save  during  the  momentary  act  of  deglutition,  are, 
first,  that  the  tympanum  may  be  generally  a  closed  cavity,  so  that 
the  sonorous  vibrations  reaching  it  may  be  concentrated  upon  the 
membrane  of  the  fenestra  rotunda  ;  and,  second,  that,  as  specially 
pointed  out  by  Dr.  Jago,  sounds  may  be  prevented  entering  the  tym- 
panum from  the  fauces.^ 

PATHOLOGICAL    OBSERVATIONS. 
Although  from  the  preceding  remarks  there  can  remain  little  doubt 

«  An  examination  of  the  faucial  orifice  of  the  Eustachian  tube  in  other  animals  is  corro- 
borative of  the  view  above  advanced.  In  inammalia  the  faucial  orifice  of  the  tube  pre- 
sents much  variety  both  in  structure  and  form.  In  the  animals  I  have  dissected  belonging 
to  the  class  ruininantia,  there  is  an  entire  absence  of  cartilage  at  the  orifice  of  the  tube, 
and  the  aperture  is  guarded  by  a  thin  fold  of  elastic  membrane ;  it  is  opened  by  the  faucial 
muscles.  In  the  cartiivora  the  cartilage  is  prominent,  and  forms  a  distinct  rounded  pro- 
jection. In  the  rodentia  the  orifice  consists  merely  of  a  fissure  in  the  mucous  membrane 
of  the  fauces.  In  some  of  the  mammalia  the  orifice  is  opened  by  the  superior  constrictor  of 
the  pharynx.  In  all  the  birds  that  I  have  been  able  to  examine,  the  Eustachian  tube  was 
composed  of  two  distinct  portions,  the  membranous  and  the  osseous  j  and  no  cartilage  en- 
tered into  their  composition.  The  membranous  portion  consists  of  a  sac,  which  is  common 
to  both  ears,  the  upper  extremity  of  which  receives  the  two  osseous  tubes,  and  the  lower 
extremity  opens  into  the  cavity  of  the  fauces  posterior  to  the  aperture  of  the  nares.  The 
muscles  which  open  the  Eustachian  tube  in  the  bird  are  the  internal  pterygoid,  or  rather 
small  muscles  distinct  from  the  pterygoid,  but  accessory  to  them.  The  common  membra- 
nous tube  is  situated  between  the  internal  pterygoid  muscles,  and  the  lateral  surfaces  of  the 
tube  are  in  contact  with,  and  firmly  adherent  to,  the  inner  surface  of  these  muscles  or  their 
accessories,  so  that  when  the  fibres  are  drawn  from  the  median  line  the  walls  of  the  tube  are 
separated,  and  a  free  communication  exists  between  the  tympanic  cavity  and  the  pharynx. 


218  '  THE     DISEASES     OF    THE     EAR. 

that  the  faucial  orifice  of  the  Eustachian  tube  is  ordinarily  closed, 
except  during  the  act  of  deglutition,  it  is  requisite  to  perfect  hear- 
ing that  the  tube  should  be  pervious,  and  that  there  should  be  a  con- 
stant interchange  of  air  in  the  cavity  of  the  tympanum.  If  the 
Euf^tacliian  tube  becomes  impervious,  the  air  that  was  in  the  tym- 
panum at  the  time  of  the  closure  gradually  disappears.  It  is  not 
easy  to  decide  whether  it  is  absorbed,  or  whether  by  a  kind  of  exos- 
mose  it  passes  through  the  membrana  tympani ;  but  whatever  the 
cause,  in  a  space  of  time,  varying  in  different  cases  from  a  few  hours 
to  a  day  or  two,  there  is  no  doubt  that  the  air  in  the  tympanic 
cavity  becomes  partially  exhausted.  The  effect  is  to  produce  an 
increased  concavity  in  the  external  surface  of  the  membrana  tym- 
pani ;  a  forcing  inwards  of  the  chain  of  ossicles  ;  pressure  on  the 
contents  of  the  labyrinth ;  and  a  very  serious  diminution  of  the 
hearing  power. 

The  morbid  conditions  of  the  Eustachian  tube  found  in  1523  dis- 
sections were  as  follows  : — 

Containing  mucus,           ...........  10 

Containing  mucus,  lining  membrane  congested,      ......  2 

Containing  mucus,  lining  membrane  thick,     .......  2 

Lining  membrane  congested,  ..........  5 

Faucial  portion,  mucous  membrane  red  and  soft,    ......  2 

Bands  of  adhesion  connecting  the  walls,  .....  .3 

Stricture  in  osseous  part,          ..........  1 

Stricture  in  cartilaginous  part,        .........  2 

Ver)'  large,     .............  2 

The  causes  of  obstruction  of  the  Eustachian  tube  may  be  thus 
classified. 

1.  At  its  faucial  orifice  ;  a  thickening  or  relaxation  of  the  mucous 
membrane. 

2.  At  its  tympanic  orifice  ;  thickening  of  the  mucous  membrane, 
or  a  deposit  of  fibrin. 

3.  In  the  middle ptcirt  of  the  tube;  a  collection  of  mucus,  a  stric- 
ture of  the  osseous  or  cartilaginous  portions,  or  membranous  bands 
connecting  the  walls. 

1.  Obstruction  of  the  Eustachian  tube,  at  its  faucial  orifice  takes 
place — 

{a.)  From  thickened  mucous  membrane. 
{h.)  From  relaxed  mucous  membrane. 


THE    EUSTACHIAN    TUBE.  219 


(a.)    OBSTRUCTION   OF   THE    FAUCIAL   ORIFICE    FROM   THICKENED 
MUCOUS   MEMBRANE. 

In  these  cases  there  is  usually  enlargement  of  the  tonsils,  or 
hypertrophy  of  the  mucous  membrane  of  the  nose  and  fauces.  If 
the  obstruction  occurs  in  a  young  person,  the  mucous  membrane  of 
the  nose  is  commonly  so  thick  as  to  ofter  some  resistance  to  the  easy 
passage  of  air,  and  to  lead  to  the  habit  of  breathing  through  the 
mouth  ;  a  habit  which  at  night  is  carried  out  to  a  marked  degree, 
and  the  patient  often  snores  loudly.  Upon  examining  the  fauces, 
the  tonsils  are  sometimes  found  enlarged,  and  the  fiiucial  mucous 
membrane  is  thicker  than  natural.  In  the  adult  the  latter  condition 
is  observed,  but  the  tonsils  are  less  frequently  affected.  The  deaf- 
ness comes  on  usually  rather  rapidly,  often  subsequent  to  a  cold, 
and,  after  remaining  for  a  time,  suddenly  vanishes  with  a  loud  crack 
in  the  ear.  This  amelioration  often  accompanies  the  acts  of  yawn- 
ing, gargling,  or  other  strong  muscular  effort  of  the  fauces.  The 
improved  hearing  which  thus  results  rarely  continues  long  ;  some- 
times it  lasts  for  a  few  hours,  in  others  for  a  day :  a  variation  which 
probably  depends  upon  the  intervals  which  elapse  before  the  air  dis- 
appears from  the  tympanic  cavity.  The  amount  of  hearing  depends 
upon  the  quantity  of  air  in  the  tympanum.  Sometimes  the  patient 
has  to  be  loudly  spoken  to  close  to  the  ear  ;  at  others  a  distinct 
voice  is  heard  at  the  distance  of  two  or  three  yards.  There  is  fre- 
quently complaint  of  a  sensation  of  weight  or  pressure  in  the  ears, 
which  often  extends  to  the  head,  Avhen  heaviness  and  great  depres- 
sion of  spirits  are  experienced.  The  latter  symptom  is  very  marked 
at  times,  but  entirely  vanishes  with  the  removal  of  the  obstruction. 

It  possibly  may  originate  from  the  pressure  exerted  upon  the 
contents  of  the  labyrinth  by  the  forcing  inwards  of  the  membrana 
tympani  and  ossicles.  A  peculiar  symptom  sometimes  met  with  in 
this  affection,  and  for  Avhich  I  am  unable  to  account,  is  the  improve- 
ment which  takes  place  during  the  temporary  position  of  the  head 
on  a  pillow,  or  even  if  it  be  turned  round  and  kept  looking  back- 
wards. Irritation  is  often  complained  of  in  the  external  meatus  ; 
sometimes  the  dermis  of  the  meatus  becomes  much  congested,  and 
eventually  pours  out  a  discharge  ;  and  where  it  happens  that  the  ir- 
ritation is  still  greater,  a  polypus  forms,  and  there  is  a  large  quan- 
tity of  mucus  secreted.    When  a  patient  presents  himself  for  advice, 


220  THE    DISEASES     OF    THE    EAR. 

with  obstruction  of  tlie  Eiistacliian  tube  coexisting  with  polypus  or 
the  sympathetic  discharge  from  the  meatus,  unless  the  case  be  most 
carefully  examined  the  real  disease  is  apt  to  be  overlooked,  and  con- 
sidered to  be  an  affection  of  the  meatus  only. 

On  inspecting  the  membrana  fi/mpani,  it  will  be  found  very  con- 
cave, of  a  dull  leaden  hue,  and  its  surface  of  an  unnatural,  glassy 
aspect,  the  triangular  spot  being  larger  than  natural.  Sometimes 
the  membrana  tympani  is  so  much  drawn  inwards  as  to  approach 
the  stapes,  which  is  distinctly  discernible  through  it ;  in  other  cases, 
the  membrana  tympani  is  somewhat  opaque,  and  its  outer  surface 
uneven  and  irregular. 

The  exploration  of  the  Eustachian  tube. — The  method  of  doing 
this  is  so  important  to  a  thorough  examination,  as  to  require  to  be 
treated  in  detail.  In  a  paper  read  before  the  Medico-Chirurgical 
Society  in  1853,  I  pointed  out  a  simple  mode  of  ascertaining 
whether  the  Eustachian  tube  was  pervious,  and  one  which,  as  a 
general  rule,  is  successful,  without  having  recourse  to  the  catheter. 
It  has  already  been  shown,  that  during  the  act  of  deglutition,  with 
the  mouth  and  nose  closed,  a  small  quantity  of  air  is  passed  through 
the  Eustachian  tubes  into  the  tympanic  cavities ;  a  process  that  is 
attended  with  a  sensation  of  fulness  in  the  ears.  The  entrance  of 
air  into  the  tympanum  can  be  distinctly  heard  by  means  of  an 
elastic  tube  about  eighteen  inches  long,  each  end  of  which  is  tipped 
with  ivory  or  ebony ;  an  instrument  which  I  have  named  the  Oto- 
scope. One  end  of  it  is  to  be  inserted  into  the  ear  of  the  patient, 
and  the  other  into  that  of  the  medical  man,  who  must  take  care 
that  no  portion  of  the  tube  touches  any  ncighlioring  body.  When 
the  patient  swallows  a  little  saliva,  the  mouth  and  nose  being  closed, 
if  the  Eustachian  tube  be  pervious,  at  the  moment  that  he  feels  a 
sensation  of  fulness  in  the  ear,  the  surgeon  will  hear  most  distinctly 
a  faint  crackling  sound,  produced  apparently  by  a  slight  movement 
of  the  membrana  tympani.  This  crackling  sound  is  that  most 
usually  heard ;  but  in  some  instances  where  the  mucous  membrane 
of  the  tympanum  is  thick,  a  gentle  flapping  sound  will  be  detected 
in  its  place.  If  in  a  case  of  suspected  obstruction  of  the  Eusta- 
chian tube,  the  otoscope  fail  to  reveal  any  sound  during  the  act  of 
deglutition  ;  if  no  sound  be  heard  when  the  patient  makes  a  forcible 
attempt  at  expiration  with  mouth  and  nose  tightly  closed  ;  and  if 
the  history  of  the  case,  the  symptoms  and  appearances,  agree  with 
those  already  laid  down  as  appertaining  to  obstruction  of  the  Eusta- 


THE     EUSTACHIAN    TUBE.  221 

cliian  tube,  I  think  the  surgeon  is  justified  in  affirming  that  the 
tube  is  obstructed,  and  has  no  need  to  resort  to  the  use  of  the 
Eustachian  catheter.     Doubtless,  in  many  cases,  a  person  is  unable 

Fig.  77. 


The  Otoscope. 

to  force  air  into  the  tympanum,  although  the  pervious  condition  of 
the  Eustachian  tube  is  shown  by  the  test  of  the  otoscope,  and  this 
may  depend  upon  a  peculiar  arrangement  of  the  lips  of  the  tube 
which  causes  them  to  be  pressed  together  by  the  compressed  air. 
There  are  other  cases  also  where  the  tube  may  be  proved  to  be 
pervious  by  the  patient  forcing  air  into  it  during  an  attempt  at 
expiration,  although  the  act  of  deglutition  with  closed  nostrils  does 
not  call  forth  any  sound  appreciable  by  the  otoscope ;  but  it  is  rare 
indeed  for  a  pervious  tube  to  resist  both  of  these  tests.  I  have, 
however,  met  with  such  cases ;  but,  as  their  history,  appearances, 
and  symptoms  have  concurred  in  showing  that  no  obstruction  of 
the  tube  existed,  it  has  not  appeared  necessary  to  introduce  the 
catheter.  In  certain  cases  the  membrana  tympani  may  be  seen  to 
move  during  an  attempt  at  expiration,  even  though  no  sound  could 
be  heard ;  the  patient,  therefore,  should  always  be  asked  whether 
he  perceives  any  sensation  in  the  ears  during  the  above-named 
processes. 

Is  the  Eustachian  catheter  then  useless  as  a  means  of  diasnosis  ? 
Notwithstanding  its  frequent  use  by  surgeons  in  Germany  and  in 
France,  I  am  disposed  to  think  so.  By  paying  attention  to  the 
points  just  laid  down,  it  is  my  opinion  that  a  case  of  obstruction  of 
the  Eustachian  tube  can  always  be  diagnosed  without  the  aid  of  the 


222 


THE    DISEASES     OF    THE    EAR. 


catheter.     Respecting  its  use  as   a  remedial  agent,  I  shall  speak 
hereafter. 

That  the  cause  of  the  obstruction  of  the  Eustachian  tube  at  its 
faucial  orifice  is  the  thickening  of  the  mucous  membrane,  is  proved 


Fio. 


The  Surgeon  using  the  Otoscope. 


by  actual  dissection,  by  the  coexistent  thickening  of  the  mucous 
membrane  in  other  parts  of  the  fiiuces,  and  by  the  results  of  the 
remedial  measures  adopted  for  its  relief.  An  opinion  formerly  ob- 
tained a  certain  degree  of  credence  in  the  medical  profession,  that 
enlarged  tonsils  frequently  press  upon  and  close  tlie  Eustachian 
tubes.  There  can  be  no  doubt  this  opinion  is  erroneous.  To  con- 
vince himself  that  it  is  so,  the  surgeon  has  only  to  make  an  ex- 
amination of  the  relative  position  of  the  tonsil  and  of  the  trumpet- 
shaped  extremity  of  the  tube ;  Mhen  he  will  find  the  tonsil  situated 
from  an  inch  and  a  quarter  to  an  inch  and  a  half  below  the  tube,  and 
placed  between  the  palato-glossus  and  palato-pharyngeus  muscles, 
the  latter  muscle  entirely  separating  the  tonsil  from  the  fube :  he 
will  also  find  the  Eustachian  tube  close  to  the  base  of  the  skull, 
against  the  basilar  process  of  the  occipital  bone,  and  surrounded  by 
the  tensor  and  levator  palati  muscles,  the  function  of  which  is,  as 
already  shown,  to  open  the  tube.  Repeated  examinations  have  con- 
vinced me  that  even  should  the  tonsil  enlarge  to  its  greatest  possible 


THE     EUSTACHIAN    TUBE.  223 

known  extent,  it  never  reaches  the  Eustachian  tube ;  for,  together 
"with  the  enlargement  of  the  tonsils,  the  palato-pharyngeus  muscle 
also  hypertrophies,  and  effectually  separates  the  two  organs.  Nay, 
further,  in  the  cases  seen  by  me,  where  the  tonsils  have  been  the 
largest,  there  has  been  no  deafness ;  a  fact  which  must  also  have 
been  observed  by  other  medical  men.  Often,  in  a  case  of  obstructed 
Eustachian  tube  in  one  ear,  the  tonsil  has  been  comparatively  small 
on  the  deaf  side ;  while  on  the  opposite  side,  Avhere  tlierc  has  been 
no  deafness,  the  tonsil  has  been  large.  There  is  no  doubt  that  ob- 
struction from  hypertrophy  of  the  mucous  membrane  of  the  faucial 
orifice  of  the  Eustachian  tube  may  coexist  with  enlarged  tonsils  ;  but 
the  mere  coexistence  of  two  affections  must  not  be  confounded  with 
cause  and  effect. 


TREATMENT    OF    OBSTRUCTION    OF   THE    FAUCIAL    ORIFICE    OF    THE 
EUSTACHIAN    TUBE    BY    THICKENED    MUCOUS    MEMBRANE. 

Cases  of  this  disease,  when  uncomplicated  with  any  affection  of 
the  tympanum,  ordinarily  yield  to  the  use  of  general  remedies  and 
applications  to  the  fauces,  without  touching  the  outer  ear.  The 
object  to  be  aimed  at  is  the  reduction  of  the  congestion  and  hyper- 
trophy of  the  mucous  membrane  surrounding  the  orifice  of  the  tube, 
so  as  to  allow  the  muscles  again  to  exercise  their  function  of  opening 
it ;  and  for  this  purpose  considerable  patience  and  perseverance  are, 
doubtless,  frequently  required  ;  since  in  many  strumous  persons, 
especially  if  young,  the  tendency  to  congestion  and  thickening  is 
very  great. 

General  Remedies. — The  most  efficient  of  these  are  abundant  and 
active  exercise  in  the  open  air,  and  warm  clothing.  Flannel  should 
be  worn  next  to  the  skin.  In  youths  the  flannel  jacket,  extending 
from  the  neck  to  the  ribs,  may  not  only  be  worn,  but,  in  cold  weather, 
in  front,  where  the  chest  is  exposed,  a  small  additional  piece  of  flan- 
nel may  be  worn  suspended  from  the  neck.  The  throat  should  not 
be  wrapped  up  with  handkerchiefs,  comforters,  boas,  &c.,  as  they 
only  serve  to  weaken  it,  by  keeping  it  Avarm  for  a  certain  time,  and 
then,  on  their  removal,  leaving  it  exposed  frequently  to  a  colder  air 
within  doors  than  had  prevailed  without,  thus  bringing  on  relaxation 
of  the  mucous  membrane.  Where  a  single  tie-handkerchief  is  worn 
within  doors,  no  addition  is  needed  on  going  out ;   and  where  in 


224  THE    DISEASES    OF    THE    EAR. 

cliilclrcn  the  throat  is  left  bare  •within  the  house,  a  small  silk  hand- 
kerchief, loosely  tied,  is  all  that  is  required  without.  I  have  been 
thus  particular  on  these  points,  because  experience  frequently  con- 
vinces me  of  their  great  importance. 

The  surface  of  the  body  should  be  daily  sponged  or  rubbed  with  a 
coarse  towel  that  has  been  dipped  in  cold  water,  and  then  wrung 
out.  As  the  children  who  suftcr  from  the  affection  under  conside- 
ration have  usually  a  languid  circulation  and  deficient  nervous 
energy,  the  towel  bath  appears  to  be  a  remedy  advantageous  in 
both  respects.  The  towel  should  be  very  coarse,  and  only  one  part 
of  the  body  should  be  rubbed  at  a  time.  The  skin,  especially  that 
of  the  neck,  throat,  and  spine,  should  be  brought  to  a  ruddy  glow. 
This  bath  may  be  used  either  in  the  morning  or  the  evening,  but 
once  daily  is  sufficient.  If  the  patient  be  so  very  delicate  that  he 
cannot  well  bear  the  slight  shock  produced  by  the  cold  towel,  tepid 
water  may  be  used.  In  addition  to  this  bath,  indeed  to  supersede 
it,  especially  in  youths  of  from  fourteen  to  sixteen,  by  whom  it  is 
not  likely  to  be  carried  out  effectually,  the  tepid  or  cold  plunge-bath 
may  be  resorted  to.  AVhen  it  can  be  practised,  sea-bathing  should 
not  be  neglected;  but  in  all  cases  of  entire  immersion  it  is  advisable 
to  wear  an  oil-skin  cap,  to  keep  the  head  dry:  and  this,  not  because 
the  application  of  water  to  the  head  is  objectionable,  but  because 
there  is  so  great  a  difficulty  in  perfectly  drying  the  hair,  and  the 
slow  evaporation  from  it  is  often  decidedly  injurious.  Plunging 
into  a  fresh-water  river  in  warm  Aveather  is  not  prejudicial.  In  the 
treatment  of  the  cases  in  question,  too  much  stress  cannot  be  laid 
upon  the  necessity  of  exercise,  bracing  air,  and  cold  bathing.  I 
have  known  them  to  overcome  the  most  obstinate  cases  of  obstruc- 
tion of  the  faucial  orifice  of  the  Eustachian  tubes,  where  all  local 
remedies  and  medicines  had  given  slight  or  only  temporary  relief. 
Care  should  also  be  taken  as  to  the  diet  of  the  patient :  pastry, 
sweets,  fat,  &c.,  should  be  avoided  ;  vegetables  may  be  sparingly 
partaken  of;  and  the  principal  food  should  be  bread,  especially  that 
containing  the  bran,  meat,  and  light  puddings,  as  rice,  sago,  &c. 
Children  should  not  be  overworked  in  their  studies,  should  retire 
early,  and  their  sleeping-rooms  should  be  airy  and  well  ventilated 
(it  is  a  good  plan  to  leave  the  bedroom  door  ajar  during  the  whole 
of  the  night) ;  and,  above  all,  it  is  important  that  the  head  should 
be  kept  above  the  bedclothes. 

To  overcome  the  very  prevalent  habit  of  breathing  through  the 


THE    EUSTACHIAN    TUBE.  225 

mouth,  whereby  the  cokl  air  keeps  up  a  constant  irritation  of  the 
faucial  mucous  membrane,  the  patient  shoukl  be  directed  to  sit  down 
quietly  for  a  certain  time  daily,  and  practise  the  habit  of  nasal 
respiration.  Although  it  may  at  first  seem  difficult,  the  mucous 
membrane  of  the  nose  soon  yields,  and  the  air  passes  freely.^ 

Medicines. — All  medicines  that  impart  tone  to  the  system,  may 
in  turn  be  resorted  to.  Cod-liver  oil,  iron  in  various  forms,  iodide 
of  iron,  iodide  of  potassium,  creasote,  and  the  mineral  acids  and 
vegetable  bitters,  will  be  found  useful. 

Local  Treatment. — The  most  efficient  local  application  is  undoubt- 
edly the  nitrate  of  silver,  which  may  generally  be  used  in  a  solid 
form.  Messrs.  Weiss  have  made  for  me  a  caustic  holder,  the  end 
of  which  is  capable  of  being  turned  at  such  an  angle,  that  the 
caustic  may  be  passed  behind  the  soft  palate,  and  applied  to  the 
mucous  membrane  of  the  orifice  of  the  tube,  as  well  as  to  that  of 
the  fauces.  Should  the  tonsils  be  enlarged,  the  solid  nitratt  of 
silver  may  be  rubbed  over  their  surface,  and  over  that  of  the  faucial 
mucous  membrane,  about  once  a  week ;  and  it  should  produce  con- 
siderable irritation  and  a  copious  flow  of  mucus.  Stimulating 
gargles  are  also  to  be  used ;  those  combining  acids  and  astringents 
are  of  service.  Iced  or  cold  water  is  often  beneficial  ;  and  in  order 
to  insure  the  application  of  the  cold  Avater  to  the  orifices  of  the 
tubes,  as  well  as  to  improve  the  condition  of  the  mucous  membrane 
of  the  nares,  the  water  may  be  drawn  up  through  the  nose,  and 
passed  out  by  the  mouth.  "When  there  is  much  congestion  of  the 
faucial  raucous  membrane,  a  leech  or  two,  a  stimulating  liniment,  or 
a  vesicating  paper,  may  be  applied  over  the  region  of  the  tonsils. 

TJie  use  of  the  Eustachian  catheter. — It  Avas,  and  is  even  noWy 
the  custom  of  some  surgeons  to  pass  the  Eustachian  catheter  re- 
peatedly in  cases  of  obstruction  of  the  Euotachian  tube.  Now^ 
what  is  the  effect  of  this  procedure  ?  If  the  mucous  membrane  be 
not  much  thickened,  air  is  blown  into  the  tympanic  cavity,  and  the 
power  of  hearing  is  improved.  As  soon,  however,  as  the  catheter 
is  withdrawn,  the  tube  again  closes,  and  its  muscles  have  not  the 
power  to  reopen  it  ;  while  the  air  which  has  been  forced  into  the 
cavity  soon  disappears,  and  the  deafness  returns.  The  patient 
again  seeks  relief  from  the  same  process  and  with  the  same  result ; 

'  Many  years  ago  I  pointed  out  the  peculiar  erectile  tissue  of  which  the  nasal  mucous 
membrane  is  composed,  not  only  in  man,  but  in  most  mammalia ;  this  tissue  renders  it  a 
most  eflBcient  natural  "respirator.'" 

15 


226  THE     DISEASES     OF    THE     EAR. 

for  if  the  mucous  membrane  is  allowed  to  remain  in  its  existing 
state,  no  permanent  relief  is  to  be  hoped  for  ;  on  the  contrary,  the 
repeated  use  of  the  catheter  tends  rather  to  increase  than  diminish 
\he  congested  state  of  the  membrane.  Under  certain  circum- 
stances, however,  the  Eustachian  catheter  is  of  great  value.  The 
judicious  course  respecting  it,  is  to  use  the  above-named  plans  for 
the  purpose  of  reducing  the  hypertrophy  of  the  mucous  membrane, 
which  will,  in  the  majority  of  cases,  eflFect  the  cure  of  the  disease. 
If,  after  pursuing  these  measures  for  ten  days  or  a  fortnight,  no 
amelioration  ensues,  the  Eustachian  catheter  may  be  introduced  and 
air  blown  through  the  tube  into  the  tympanum  ;  an  operation  which 
may  at  times  possibly  facilitate  a  cure  by  the  removal  of  mucus 
from  the  tube,  or  by  liberating  the  lips  of  the  faucial  orifice.  Seve- 
ral days,  however,  should  elapse  before  the  operation,  if  required,  is 
repeated,  and  this  will  seldom  be  the  case. 

The  mode  of  applying  the  Eustachian  catheter. — It  has  been 
already  stated  that  the  orifice  of  the  Eustachian  tube  is  posterior 
and  external  to  the  posterior  aperture  of  the  inferior  nasal  meatus. 
The  catheter  used  by  me  is  not  quite  so  large  as  an  ordinary  crow- 
quill  ;  and  as  the  outer  part  of  the  Eustachian  tube  is  oval,  it  has 
been  recently  suggested  by  me  that  the  extremity  of  the  catheter 
should  be  of  the  same  shape.  The  end  of  the  catheter  taken  hold 
of  by  the  surgeon  should  be  rather  larger  than  that  which  is  to 
enter  the  tube,  in  order  that  the  end  of  the  explorer,  or  the  nozzle 
of  a  syringe,  may  be  fixed  in  it.  This  end  having  a  ring  on  the 
side  opposite  to  the  concavity  of  the  curved  end,  is  to  be  taken  in 
the  right  hand  of  the  surgeon,  the  patient  being  seated  in  the  chair 
before  him,  and  then  the  instrument,  Avith  the  point  downwards,  is 
to  be  made  to  glide  backwards,  by  the  side  of  the  septum  nasi,  until 
the  curved  end  reaches  the  cavity  of  the  fauces,  when  it  is  to  be 
pressed  backwards  against  the  mucous  membrane  of  the  posterior 
part  of  the  fauces.  It  is  next  to  be  drawn  slightly  forwards,  and 
then  rotated  outwards,  so  that  the  extremity  may  turn  upwards  and 
catch  the  orifice  of  the  Eustachian  tube,  which  can  be  distinctly  felt, 
and  will  prevent  the  further  rotation  of  the  instrument.  The  cathe- 
ter is  now  to  be  pressed  slightly  outwards  and  backwards,  when  the 
surgeon  will  feel  it  to  be  embraced  by  the  tube.  For  the  purpose 
of  securing  the  instrument,  a  frontlet  bandage,  with  a  pair  of  for- 
ceps attached,  has  been  used  ;  but  it  may  be  dispensed  with  in  all 
ordinary  cases  :  for  the  surgeon  has  only  to  transfer  the  catheter  to 


THE     EUSTACHIAN     TUBE. 


227 


his  left  hand,  and  while  holding  it  lightly,  so  as  not  to  cause  pain  to 
the  patient  (as  the  use  of  the  frontlet  invariably  does),  insert  into 
the  dilated  end  of  that  instrument  the  small  end  of  the  explorer  or 
of  the  syringe.     The  explorer,  which  in  my  hands  has  entirely  super- 


FiG.  79. 


The  Explorer,  and  the  Eustachian  Catheter  into  which  it  fits. 

seded  the  use  of  the  air-press,  consists  of  an  elastic  tube,  about 
eighteeen  inches  long,  one  end  of  which  has  a  flat  mouth-piece  of 
ivory,  with  one  or  two  deep  incisions  upon  it,  to  enable  it  to  be 
easily  held  by  the  incisor  teeth  of  the  operator,  Avhile  the  other  end 
has  a  small  portion  of  steel  tubing  attached  to  it,  which  fits  accu- 
rately into  the  further  end  of  the  catheter. 

"When  the  catheter  has  been  properly  fixed,  as  directed  in  the 
tube,  and  held  there  by  the  left  hand  of  the  surgeon,  one  end  of  the 
explorer  is  to  be  placed  in  his  mouth,  and  the  other  in  the  catheter, 
and  held  there  also  by  the  left  hand.  With  his  right  hand,  thus 
left  at  liberty,  the  surgeon  is  now  to  take  the  otoscope  and  introduce 
one  end  of  it  into  the  car  of  the  patient,  who  may  hold  it  there,  the 
other  end  being  held  by  the  surgeon  in  his  own  ear  ;  or  the  tube 
may  be  made  so  light  as  to  remain  there  without  being  held,  leaving 
the  operator's  right  hand  still  free. 

The  medical  man  next  proceeds  to  blow  air  gently  through  the 
explorer,  at  the  same  time  that  he  listens  through  the  otoscope  to 
ascertain  whether  the  air  enters  the  ear,  and  if  it  does,  what  is  the 
peculiar  sound  it  produces.  When  the  tympanum  is  unobstructed 
by  mucus,  the  air  is  heard  to  pass  in  a  stream  against  the  inner 
surface  of  the  membrana  tympani,  but  when  mucus  is  present,  a 
peculiar  gurgling  is  heard  ;  and  if  the  mucous  membrane  itself  is 
thickened,  a  peculiar  squeak  or  bubbling  is  also  perceptible.     It  is 


228 


THE    DISEASES     OF    THE    EAR. 


not  advisable  to  blow  with  force  into  the  ear,  but  rather  to  make  a 
few  gentle  successive  puffs,  attentively  listening  during  each,  to 
detect  the  kind  of  sound  that  may  be  heard  in  the  tympanum. 


Fig.  80. 


The  Surgeon  using  the  Eustachian  Catheter  and  the  Explorer. 


Sometimes  no  air  enters,  the  mucous  membrane  being  too  thick  to 
allow  it  to  pass ;  and,  under  such  circumstances,  it  is  unwise  to 
attempt  to  force  the  air  into  the  tympanum.  Great  mischief  has, 
indeed,  frequently  resulted  from  such  a  proceeding;  the  mucous 
membrane  having  been  lacerated,  and  the  air  been  driven  into  the 
submucous  tissue,  causing  extensive  emphysema.  Nay,  still  more 
serious  results  have  occurred,  the  patient  having  been  killed  in- 
stantaneously, perhaps  through  the  effusion  of  air  through  the 
fenestra  rotunda  (the  membrane  having  been  lacerated)  into  the 
labyrinth,  and  the  shock  upon  the  nervous  system  causing  instant 
death.  Xor  need  it  be  a  source  of  surprise  that  the  effusion  of  air 
into  the  labyrinth  should  prove  fatal,  since  even  the  forcible  disten- 
sion of  the  tympanum,  while  blowing  the  nose  frequently,  produces 
giddiness  by  pressure  upon  the  labyrinth. 

Tlie  excmon  of  the  tonsils. — On  the  supposition  that  the  tonsil, 
when  enlarged,  pressed  against  and  closed  the  faucial  orifice  of  the 
Eustachian  tube,  the  operation  for  excision,  or  partial  excision,  of 
the  tonsils,  has  long  been  practised  for  the  relief  of  deafness.     Al- 


THE    EUSTACHIAN    TUBE.  229 

though,  as  already  shown,  the  tonsil,  however  hypertrophied,  cannot 
cause  occlusion  of  the  Eustachian  tuhe,  still  the  removal  of  a  portion, 
in  cases  where  it  is  much  enlarged,  is  sometimes  of  service  by  dimin- 
ishing the  conjiestion  of  the  mucous  membrane  at  the  orifice  of  the 
tube ;  and  it  perhaps  also  operates  beneficially  by  allowing  the 
muscles  of  the  tube  to  act  more  freely.  This  operation  is,  however, 
very  rarely  required ;  and  the  best  rule  to  follow  is  never  to  excise 
a  portion  of  the  tonsil,  which  appears  to  have  important  functions, 
independent  of  the  fauces,  unless  it  evidently  interferes  with  the 
general  health  of  the  patient,  or  unless  the  obstruction  of  the 
Eustachian  tube  resists  the  other  measures  already  indicated. 


CASES    OF    THE    OBSTRUCTION    OF    THE    EUSTACHIAN   TUBE    BY    THICK- 
ENED   MUCOUS    MEMBRANE,    AT    ITS    FAUCIAL    ORIFICE. 

Case  I. — Master  M.  J.,  aged  15,  was  brought  to  consult  me,  on 
December  4,  1852,  on  account  of  a  very  serious  diminution  of  the 
hearing  power,  in  both  ears.  He  Avas  in  tolerable  health,  but  pale. 
About  a  year  previously,  after  suffering  from  a  bad  cold,  he  became 
dull  of  hearing,  and  since  then  has  been  able  to  hear  only  when 
spoken  to  in  a  loud  voice,  within  the  distance  of  a  yard  or  two. 
Occasionally  he  has  felt  a  sensation  as  of  something  bursting  in  the 
ears,  which  has  been  followed  by  slight,  but  only  temporary  relief. 
Upon  examination,  the  mucous  membrane  of  the  fauces  was  found 
very  thick  and  red,  and  both  tonsils  greatly  enlarged.  The  right 
ear. — Watch  heard  only  when  in  contact  with  the  ear ;  the  membrana 
tympani  being  opaque,  of  a  leaden  hue,  and  more  concave  externall}'' 
than  natural,  while,  instead  of  the  usual  triangular  bright  spot,  tAvo 
bright  spots  Avere  perceptible,  showing  that  the  membrane  was  de- 
prived of  its  ordinary  evenness  of  surface.  Upon  listening  with  the 
otoscope  while  the  patient  swallowed,  the  mouth  and  nose  being 
closed,  and  while  he  tried  to  force  air  into  the  tympanum,  no  sound 
was  heard.  The  left  ear  was  in  a  very  similar  state  to  the  right ; 
the  watch,  however,  could  be  heard  at  a  distance  of  two  inches  from 
the  ear.  Feeling  assured  from  the  history  of  the  case,  the  symp- 
toms, the  condition  of  the  throat,  the  appearances  of  the  ear,  and 
the  negative  results  following  the  use  of  the  otoscope,  that  the 
Eustachian  tube  Avas  closed  at  the  faucial  orifice,  especially  as  there 
Avas  no  indication  of  disease  in  the  tympanum,  Avhich  might  lead  to 


230  THE    DISEASES     OF    THE    EAR. 

the  supposition  of  tlie  tympanic  orifice  being  affected,  I  did  not  use 
the  Eustacliian  catlieter,  but  proceeded  at  once  to  apply  a  solution 
of  nitrate  of  silver  to  the  mucous  membrane  of  the  fauces,  and  to  the 
orifices  of  the  Eustachian  tubes.  Three  grains  of  the  sulphate  of 
iron  -were  given  daily  in  combination  with  ten  grains  of  sulphate  of 
magnesia,  and  slight  counter-irritation  was  kept  up  over  the  region 
of  the  tonsils.  As  a  remedial  measure,  the  catheter  was  not  resorted 
to,  as  it  "Nvas  evident  that  the  hypertrophy  of  the  mucous  membrane 
had  slowly  come  on,  and  it  was  not  probable  that  it  could  be  other- 
wise than  slowly  improved.  The  first  effect  of  the  treatment  was  a 
slight  improvement  of  the  hearing,  although  the  tube  remained 
impervious ;  an  improvement  which  probably  depended  upon  the 
diminution  of  the  congestion  in  the  mucous  membrane  of  the  tym- 
panum. By  the  end  of  January,  the  hearing  power  of  the  right 
ear  had  greatly  improved ;  and  in  the  middle  of  February,  the  air 
passed  freely  through  the  Eustachian  tubes  during  the  act  of  deglu- 
tition, and  the  patient  heard  quite  well  again. 

Case  II.  OhistriLction  at  the  faucial  orifice  for  two  montJis. — W. 
"W.,  Esq.,  aged  52,  being  strong  and  in  good  health,  consulted  me 
on  July  26,  185-3.  He  stated  that  two  months  previously,  after  a 
bad  cold,  he  became  slowly  deaf  in  both  ears,  so  as  to  require  per- 
sons to  speak  loudly  to  him  Avithin  the  distance  of  a  yard.  On  the 
24th,  after  yawning,  he  suddenly  experienced  a  crack  in  the  left 
car,  and  as  suddenly  heard  well ;  but  this  improvement  only  lasted 
for  a  day,  and  then  the  deafness  slowly  returned.  He  has  had  three 
similar  attacks  during  the  last  ten  years,  but  in  about  a  month's 
time  the  hearing  usually  returned  after  a  cracking  sound  in  the 
ears.  At  times,  on  throwing  the  head  back,  he  has  found  the  hear- 
ing power  in  the  right  ear  much  improved.  On  examination^  the 
mucous  membrane  of  the  fauces  was  red  and  hypcrtrophied. 

lUglit  ear. — Hearing  distance  three  inches  ;  the  meatus  was  red 
and  hypcrtrophied,  the  mcmhrana  tympani  more  concave  than  natu- 
ral, its  surface  uneven,  and  instead  of  the  single  triangular  bright 
spot,  there  were  two  smaller  spots. 

Euatachian  tube. — The  otoscope  did  not  detect  any  air  entering 
the  tympanic  cavity  during  tlic  process  of  deglutition,  or  upon  an 
attempt  at  a  forci])le  expiration  with  closed  nostrils. 

Left  ear. — Watcli  heard  only  when  in  contact  with  the  ear  ;  the 
mcmbrana  tympani  was  in  a  similar  state  to  that  of  the  right  ear, 


THE    EUSTACHIAN    TUBE.  231 

and  the  long  process  of  the  incus  coukl  be  seen  through  it.  The 
Eustachian  tube  was  impervious. 

By  the  use  of  stimuLiting  gargles  and  a  liniment  over  the  ears 
and  throat,  the  patient  entirely  recovered  in  the  course  of  a  fort- 
night. 

Case  III.  Ohstruetion  of  the  faucial  orifice  :  catarrh  from  meatus : 
tonnih  very  large  :  cure  without  excision. — Master  B.,  aged  16,  was 
brought  to  consult  me  in  August,  1850.  His  general  health  was 
not  very  good,  and  he  was  subject  to  glandular  enlargements. 

History. — The  right  ear  has  always  been  slightly  dull,,  and  for 
two  or  three  years  it  has  been  worse.  The  left  ear  lately  has  also 
become  so  dull,  that  he  requires  to  be  spoken  to  distinctly  within 
the  distance  of  a  yard  from  the  head.  Has  had  several  attacks  of 
earache;  after  Avhich,  and  also  after  a  cold,  the  deafness  is  increased. 
Has  had  discharge  from  each  ear  on  several  occasions,  and  complains 
of  a  singing  in  them.  When  asleep  he  makes  a  loud  snoring  sound, 
and  he  always  breathes  through  the  nose.  At  times  has  had  a 
cracking  sound  in  the  ears,  which  has  been  followed  by  a  tempo- 
rary improvement.  On  examination,  the  tonsils  were  found  to  be 
so  greatly  enlarged  as  nearly  to  touch  the  median  line,  while  the 
mucous  membrane  of  the  fauces  and  of  the  nose  was  much  thicker 
than  natural. 

Right  ear. — Hearing  distance  half  an  inch ;  membrana  tympani 
concave  ;  bright  spot  somewhat  dull.     Eustachian  tube  impervious. 

Left  ear. — Hearing  distance  two  inches ;  the  bright  spot  of  the 
membrana  tympani  subdivided.     Eustachian  tube  obstructed. 

As  the  tonsils  in  this  case  were  so  much  larger  than  natural,  and 
as  they  apparently  interfered  Avith  the  respiration  of  the  patient, 
and  perhaps  with  his  health,  it  was  thought  that  the  removal  of  a 
portion  of  one  or  both  might  be  attended  with  benefit :  but  the  pa- 
tient's friends  so  strongly  objected  to  the  operation  that  it  was  not 
performed.  The  treatment  consisted  in  the  application  of  solid 
nitrate  of  silver  to  the  fauces ;  in  the  use  of  an  astringent  gargle 
Avith  counter-irritants  over  the  ears  and  throat ;  in  the  administra- 
tion of  tonic  medicines ;  and  in  careful  diet,  with  abundant  exercise 
in  the  open  air.  On  August  21st,  a  crack  took  place  in  the  left  ear, 
when  he  heard  perfectly  for  a  short  time.  After  this  date,  a  suc- 
cession of  cracks  was  heard  in  each  ear,  and  at  last  the  hearing 
power  entirely  returned  and  remained  perfect,  except  during  a  cold, 
the  effects  of  which,  however,  soon  disappeared. 


232  THE    DISEASES    OF    THE     EAR. 

CaseW.  Obstruction  from  the  mucous  membrane  of  the  fauces; 
polypus  in  meatus  externus ;  removal  by  operation;  cure. — H.  W., 
Esq.,  aged  19,  was  sent  to  me  by  Mr.  White  Cooper,  in  February, 
1854,  on  account  of  a  consitlerable  diminution  of  the  power  of  hear- 
ing, and  of  a  discharge  from  the  right  ear.  Ilis  health  was  not  very 
good,  and  he  was  subject  to  enlarged  cervical  glands.  The  history 
of  the  case  was,  that  about  two  years  ago  he  found  himself  becoming 
gradually  dull  of  hearing.  After  this  dulness  had  remained  some 
months,  accompanied  by  a  feeling  of  fulness  in  the  ears,  a  discharge 
took  place  from  the  right  ear,  the  quantity  of  which  has  lately  con- 
siderably increased.  On  examination,  the  mucous  membrane  of  the 
fauces  was  observed  to  be  red  and  thick. 

Right  ear. — The  watch  heard  only  when  in  contact ;  a  raspberry 
polypus,  the  size  of  a  small  pea,  Avas  seen  to  fill  the  meatus,  close  to 
the  membrana  tympani. 

Left  ear. — Hearing  distance  six  inches ;  membrana  tympani 
opaque,  and  calcareous  in  parts.  Each  Eustachian  tube  was  imper- 
vious to  air.  The  treatment  consisted  in  the  removal  of  the  polypus 
by  means  of  the  lever-ring  forceps.  The  membrana  tympani  was 
then  observed  to  be  white.  Astringent  and  acid  gargles  were  used ; 
slight  counter-irritation  was  kept  up  over  the  cars  and  the  region  of 
the  fauces  ;  tonics  were  administered  ;  and  daily  sponging  with  cold 
water  was  enjoined.  In  the  course  of  a  week  a  crack  took  place  in 
the  right  ear,  followed  by  immediate  great  improvement  of  the 
hearing  ;  this  was  succeeded  by  a  crack  in  the  left  ear,  and  a  perfect 
restoration.  The  discharge  also  wholly  disappeared.  On  seeing 
this  patient  several  months  afterwards,  I  found  his  hearing  perfect, 
and  there  had  been  no  return  of  the  discharge. 

I  have  said  that  the  use  of  the  Eustachian  catheter  is  rarely  re- 
quired, because  the  state  of  the  mucous  membrane  generally  so  much 
improves  by  means  of  the  other  remedies.  In  the  following  case, 
however,  wliere  there  was  an  additional  cause  of  impediment  besides 
the  thickened  mucous  membrane,  the  catheter  was  used  with  advan- 
tage. 

Case  V.  Impervious  condition  of  the  tube  from  hypertrophy  of  the 
mucous  membrane  at  the  faucial  orifice  ;  fissure  of  the  palate  ;  ca- 
theter used  ivith  advantage. — Dr.  P.,  a  medical  man,  aged  43,  con- 
sulted me  in  1853,  on  account  of  deafness. 

History. — Several  j'ears  previously  he  had  a  disease  of  the  palate, 
which  terminated  in  the  loss  of  a  considerable  portion  of  the  palatal 


THE    EUSTACHIAN    TUBE.  233 

processes  of  tlie  superior  maxillary  and  palatal  bones,  and  caused  a 
large  fissure.  During  tlie  last  two  or  three  years  he  has  suffered 
from  attacks  of  deafness  during  a  cold,  which,  after  continuing  for 
some  weeks,  have  disappeared.  On  cvamination,  the  mucous  mem- 
brane of  the  fauces  was  found  to  be  red  and  mucli  thicker  than  natu- 
ral. Towards  the  posterior  part  of  the  palate  was  a  large  fissure, 
exposing  the  trumpet-shaped  extremity  of  the  Eustachian  tube  ;  the 
mucous  membrane  of  which  was  much  swollen.  Each  membrana 
tympani  was  of  a  leaden  hue  and  very  concave ;  and  there  was  an 
appearance  of  redness  beyond  each,  as  if  the  mucous  meml)rane  were 
congested.  The  patient  had  to  be  spoken  to  distinctly  within  the 
distance  of  a  yard.     The  Eustachian  tubes  were  impervious. 

Treatment. — A  solution  of  nitrate  of  silver  (5ij  @  Sj)  was  applied 
to  the  mucous  membrane  of  the  fauces  and  to  the  orifices  of  the 
tubes  ;  an  astringent  gargle  was  ordered,  and  gentle  counter-irrita- 
tion over  the  throat.  This  treatment  produced  a  slight  improve- 
ment ;  but  as  the  deafness  soon  returned,  as  the  patient  Avas  espe- 
cially anxious  to  hear,  and  as  it  appeared  probable  that  the  muscles 
of  the  tube  were  partially  disabled  from  performing  their  function,  I 
passed  the  Eustachian  catheter,  and,  by  means  of  the  explorer,  blew 
air  into  the  tympanic  cavities.  The  good  effect  was  instantaneous, 
and  the  patient  heard  well.  The  improvement,  however,  lasted  for 
only  about  twelve  hours,  when  the  deafness  gradually  returned.  At 
the  desire  of  the  patient  I  passed  the  catheter  on  several  occasions, 
while  other  treatment  was  being  followed.  After  each  operation  the 
hearing  improved  for  about  the  same  space  of  time ;  ultimately  the 
condition  of  the  mucous  membrane  was  so  much  improved  as  to  allow 
the  muscles  to  open  the  tubes,  and  a  cure  resulted. 

In  some  cases  after  the  Eustachian  tube  has  been  obstructed  for 
a  long  time,  the  patient  may  almost  wholly  lose  the  power  of  hear- 
ing. These  cases,  as  will  be  seen  by  the  following  instance,  are  by 
no  means  to  be  despaired  of. 

Case  VI.  Obstruction  by  tliichened  mucous  membrane  of  the 
faucial  orifice  ;  duration  of  many  years  ;  great  and  jyrolonged  hard- 
ness of  hearing  ;  cure. — Miss  J.  A.  0.,  aged  12,  was  brought  to  me 
from  Manchester,  on  the  16th  April,  1853.  She  was  strong,  but 
rather  pale.  The  history  of  the  deafness  Avas,  that  during  several 
years  she  had  been  dull  of  hearing  during  a  cold ;  on  the  disap- 
pearance of  which,  the  power  of  hearing  partially  returned,  so  that 
she  could  hear  without  much  difficulty.     For  some  months  the  deaf- 


234  THE    DISEASES     OF    THE     EAR. 

ness  has  been  so  much  •worse,  that  she  cannot  hear  unless  spoken 
to  in  a  loud  voice  into  the  left  ear,  the  right  being  useless.  On 
examination,  the  mucous  membrane  of  the  fi\uces  Avas  found  to  be 
red,  thick,  and  spongy,  but  the  tonsils  -were  not  larger  than  natural. 
The  mucous  membrane  of  the  nose  was  very  thick  and  red ;  and 
respiration  was  usuall}'  carried  on  by  means  of  the  mouth. 

Hifjlit  ear. — Watch  heard  on  pressure,  but  indistinctly:  membrana 
tympani  concave,  surface  uneven ;  and  on  that  surface  three  irre- 
gular-shaped bright  spots  -were  seen.     Eustachian  tube  impervious. 

Left  ear. — "Watch  heard  -when  pressed;  membrana  tympani  and 
Eustachian  tube  the  same  as  in  the  opposite  ear. 

Treatment. — The  solid  nitrate  of  silver  was  directed  to  be  applied 
to  the  mucous  membrane  of  the  fauces  once  a  week ;  counter-irritation 
over  the  ears,  and  a  leech  or  two  at  times  over  the  region  of  the 
fauces ;  the  one-thirtieth  of  a  grain  of  the  bichloride  of  mercury 
twice  daily,  and  a  warm  bath  once  a  week  :  occasionally  an  emetic 
was  also  given.  She  returned  to  Manchester,  and  on  the  28th  of 
May  her  father  wrote  to  me,  saying  that  she  was  "  so  much  better 
that  she  can  keep  up  a  conversation  across  the  table."'  The  child 
had  a  relapse  in  the  following  January,  but  a  repetition  of  the 
treatment  again  restored  her  to  perfect  hearing. 

It  is  not,  hoAvever,  only  in  long-standing  cases  of  obstruction  of 
the  Eustachian  tube  that  the  deafness  is  very  considerable ;  in  weak 
persons  almost  total  deafness  may  come  on  in  a  few  hours.  A  well- 
marked  case  of  the  kind  has  occurred  to  me  while  writing  the 
present  chapter. 

Case  VII.  Sudden  ohstruction  of  each  Eustachian  tube  from  con- 
gestion and  tJiickening  of  the  mucous  membrane  of  the  fauces,  jrro- 
ducing  total  deafness  in  a  few  hours ;  cure. — Dr.  B.,  on  the  24th 
January,  1855,  called  to  ask  me  to  see  his  wife,  of  whom  he  gave 
the  following  Idstory. 

For  several  months  she  has  been  much  out  of  health,  and  confined 
to  her  room ;  but  has  never  suifered  from  any  deafness  or  dise:xse  of 
the  ear.  On  the  night  of  the  20th  instant  she  awoke,  complaining 
of  a  loud  singing  in  her  ears  ;  and  when  spoken  to,  it  was  found 
that  she  was  so  deaf  as  not  to  be  able  to  comprehend  what  was  said, 
although  addressed  very  loudly.  If  possible,  this  deafness  increased, 
so  that  on  the  22d  no  sounds  were  heard,  and  all  communication  had 
to  take  place  in  writing.  On  examination,  on  the  24th,  I  found 
that  the  deafness  was  complete  ;  each  membrana  tympani  was  very 


THE    EUSTACHIAN    TUBE.  235 

concave  and  dull ;  the  mucous  membrane  of  the  fauces  "was  very  red 
and  thick,  the  tonsils  and  uvula  much  swollen.  Each  Eustachian 
tube  was  impervious.  Upon  inquiry  I  learnt  that  accidentally  a 
part  of  the  window  had  been  left  open  during  the  night.  The 
treat)nent  recommended  was  the  application  of  the  solid  nitrate  of 
silver  to  the  fauces  and  the  orifices  of  the  Eustachian  tubes.  This 
was  done  freely  about  eleven  o'clock  on  the  2Gth.  Dr.  B.  returned 
home  about  two  hours  after,  and  found  the  hearing  so  improved  that 
he  carried  on  a  conversation  with  his  Avife  in  a  loud  voice. 

I  miirht  add  to  the  above  a  laro-e  number  of  cases  in  which  the 
treatment  was  quite  successful,  but  will  merely  give  the  leading 
particulars  of  another. 

Case  VIII. — H.  L.,  Esq.,  aged  28,  consulted  me  on  June  25, 
1853.  Has  suffered  for  several  months  from  sore  throat,  conse- 
quent upon  an  attack  of  secondary  syphilis  :  for  two  months  has 
complained  of  deafness  in  both  ears,  so  as  not  to  hear  any  except 
a  loud  voice.  The  deafness  is  accompanied  by  constant  singing, 
which  is  increased  when  the  head  is  on  the  pillow,  and  it  varies 
nuich.  On  one  occasion,  after  gargling  the  throat,  heard  much 
better  with  the  ri<i;ht  ear  for  twelve  hours.  On  examination  of  the 
rigid  car,  the  hearing  distance  was  half  an  inch  ;  the  membrana 
tympani  was  opaque  and  of  a  leaden  hue ;  the  surface  shone,  but 
the  bright  spot  was  nearer  the  circumference  of  the  membrane 
than  natural.  The  Eustachian  tube  impervious.  The  left  ear  was 
in  the  same  condition  as  the  right.  The  treatment  pursued  was 
the  use  of  the  nitrate  of  silver  to  the  fauces,  and  the  administra- 
tion of  steel  wine.  On  July  2d  he  told  me  that  three  or  four  days 
previously  he  heard  quite  well  in  the  morning,  and  the  improve- 
ment lasted  for  two  days,  since  which  he  has  been  gradually  getting 
deaf  again.  By  perseverance  in  the  treatment  for  a  month  he 
perfectly  recovered. 


(b.)    OBSTRUCTION    OF    THE    EUSTACHIAN    TUBE   AT    ITS   FAUCIAL 
ORIFICE   FROM    RELAXED    MUCOUS    MEMBRANE. 

This  affection  is  far  from  being  so  frequently  met  Avith  as  obstruc- 
tion arising  from  thickened  mucous  membrane.  In  many  symptoms 
the  two  affections  greatly  assimilate,  but  they  also  present  certain 
decided  differences.     Obstruction  from  relaxed  mucous  membrane 


236  THE     DISEASES    OF    THE     EAR. 

occurs  less  frequently  in  children  or  in  persons  subject  to  glandular 
enlargements,  than  in  persons  -who  have  no  thickening,  but  simply 
a  relaxed  state  of  the  mucous  membrane  of  the  fauces.  The 
physical  cause  of  the  obstruction  appears  to  be  a  relaxed  condition 
of  the  mucous  membrane  covering  the  faucial  orifice  of  the  tube, 
so  that  its  muscles  are  unable  to  separate  the  lips  sufficiently  to 
admit  the  air.  The  predisposing  cause  is  generally  some  debili- 
tating influence,  as  over-work,  keeping  late  hours,  indigestion,  &c. 
The  exciting  cause  is  often  a  cold.  There  is  usually  no  history  of 
any  previous  affection  of  the  ears,  the  deafness  coming  on  slowly, 
and  gradually  increasing  until  the  patient  is  unable  to  hear  ordi- 
nary conversation,  and  requires  to  be  spoken  to  in  a  loud  voice. 
Sometimes  the  patient  impi-oves  for  a  short  time,  and  then  the 
deafness  returns ;  but  frequently  the  hearing  is  better  when  the 
head  is  placed  in  a  recumbent  position,  or  when  the  face  is  turned 
and  looks  backwards.  There  is  often  a  feeling  of  weight  in  the 
ears,  Avith  a  singing  sound,  and  at  times  a  sensation  of  confusion 
in  the  head.  On  examination,  the  patient  generally  looks  pale 
and  out  of  tone ;  the  pulse  is  Aveak ;  the  mucous  membrane  of  the 
fauces  is  either  relaxed  and  red,  the  bloodvessels  bein<::f  lar<xe  and 
presenting  long  streaks ;  and  the  uvula  is  either  hanging  down,  so 
as  to  touch  the  dorsum  of  the  tongue,  or  it  is  of  a  much  paler 
color  than  natural  from  being  deprived  of  its  due  supply  of  blood. 
The  membrana  tympani  is  much  more  concave  than  natural,  fre- 
quently of  a  leaden  hue,  its  surface  being  glassy.  Not  unfrequently 
the  long  process  of  the  incus  is  seen  through  it.  Upon  exploration 
with  the  otoscope,  the  Eustachian  tube  is  found  to  be  impervious. 
The  treatment  differs  somewhat  from  that  of  cases  of  obstruction 
from  thickened  mucous  membrane.  Instead  of  nitrate  of  silver, 
stimulating  gargles  are  to  be  used — one  composed  of  whiskey  is 
often  very  serviceable ;  tonic  medicine  and  stimulants  are  to  be 
administered,  generous  diet,  rest  from  work,  country  air,  and 
abundant  out-door  exercise,  should  also  be  prescribed.  Similar 
reasons  to  those  which  induce  me  not  to  use  ordinarily  the  Eusta- 
chian catheter  in  cases  of  obstruction  from  thick  mucous  membrane, 
have  prevented  my  resorting  to  it  in  the  cases  under  consideration. 
Its  use  could  not,  of  course,  diminish  the  cause  of  obstruction,  or 
fticilitate  the  progress  of  the  treatment ;  and  unless  the  patient, 
from    some   particular   circumstances,  was   desirous    to    hear    well 


THE    EUSTACHIAN    TUBE.  237 

during  a  few  hours,  the  introduction  of  this  instrument  should  be 
avoided.     A  cure  is  always  to  be  effected  without  it. 

Case  I.  Obstruction  of  the  left  tube  from  relaxed  condition  of  the 
mucous  membrane ;  eonstant  beating  sound. — J.  R.  H.,  Esq.,  a 
surgeon,  aged  48,  consulted  me  on  December  15,  1823.  The 
history  was,  that  about  six  weeks  previously  he  found  himself  deaf 
in  the  left  ear;  he  felt  no  pain,  but  there  was  a  constant  sensation 
of  beating  in  the  ear,  and  a  weight  on  that  side  of  the  head,  which 
caused  extreme  discomfort.  He  is  subject  to  a  relaxed  throat. 
On  examination,  the  mucous  membrane  of  the  fauces  was  observed 
to  be  relaxed,  though  not  thicker  than  natural ;  the  meatus  ex- 
ternus  of  the  hft  ear  was  dry  and  smooth,  and  did  not  contain 
any  cerumen ;  the  membrana  tympani  was  very  concave  and  some- 
what opaque.  The  processus  brevis  stood  out  very  prominently ; 
but  the  manubrium  Avas  so  much  drawn  inwards  that  it  could 
scarcely  be  seen.  The  otoscope  showed  the  Eustachian  tube  to  be 
impervious.  The  watch  heard  only  in  contact  with  the  car.  The 
right  ear  perfectly  natural. 

Treatment. — A  whiskey  gargle  was  ordered,  afid  a  mustard 
plaster  to  be  placed  on  the  region  of  the  fauces ;  the  outside  of  the 
throat  to  be  rubbed  Avith  a  coarse  towel  dipped  in  cold  water  ;  simple 
food,  as  much  rest  and  as  little  "night-work"  as  possible. 

December  24th. — A  crack  took  place  in  the  ear,  and  the  hearing 
became  perfect  for  a  few  minutes,  but  again  became  gradually  dull. 
The  treatment  was  persevered  in,  and  on  the  7th  January,  1854, 
the  gentleman  wrote,  "I  am  quite  well;  the  air  passes  into  the  ear 
perfectly  well."     All  the  unpleasant  symptoms  had  subsided. 

Case  II.  Obstruction  in  each  tube  for  ten  days  after  an  attack  of 
bronchitis. — S.  S.,  Esq.,  aged  51,  an  architect,  was  brought  to  rae 
on  June  24,  1853. 

History. — He  has  had  a  bad  cough  and  bronchial  affection  for  a 
month,  which  came  on  after  having  been  considerably  over-worked. 
Ten  days  ago  deafness  came  on  slowly  in  both  ears,  and  has  re- 
mained till  now ;  so  that  he  has  to  be  spoken  to  in  an  elevated  tone 
within  a  yard.  He  hears  much  better  in  the  morning  when  reclin- 
ing in  bed.  Has  frequently  tested  his  hearing  by  means  of  his 
watch,  and  the  result  is,  that  when  lying  down  he  can  hear  it  at  a 
distance  of  two  feet  Avith  either  ear ;  but  after  being  in  the  erect 
posture  for  a  minute  or  two  the  deafness  returns,  and  he  can  hear 
the  watch  only  at  two  inches  from  the  ears.     He  has  now  and  then 


238  THE    DISEASES     OF    THE    EAR. 

had  a  sliglit  crack  in  each  ear,  followed  by  somewhat  improved  hear- 
ing. On  examination,  the  pulse  was  weak  and  slow,  the  face  pale 
and  flabby,  and  the  raucous  membrane  of  the  fauces  was  seen  to  be 
relaxed,  with  enlarged  streaky  vessels  ramifying  in  it. 

lliglit  ear. — A\  atch  heard  only  when  in  contact  Avith  the  ear ;  the 
surface  of  the  membrana  tympani  was  dull,  had  a  dark  leaden  hue, 
and  the  membrane  was  much  more  concave  than  natural,  having  two 
irregular-shaped  bright  spots  in  place  of  the  single  one ;  the  long 
process  of  the  incus  was  seen  through  the  membrana  tympani,  and 
appeared  to  be  in  contact  with  its  inner  surface ;  the  Eustachian 
tube  was  impervious. 

Left  car. — Similar  to  the  right :  hearing  distance,  a  quarter  of  an 
inch. 

The  treatment  consisted  in  the  administration  of  the  citrate  of 
iron,  followed  by  decoction  of  bark  and  sulphuric  acid ;  the  use  of 
a  tannin  gargle  and  gentle  external  counter-irritation.  He  was  also 
advised  to  sleep  in  the  country,  to  work  as  little  as  possible,  and  to 
live  generously.  On  July  2d  there  Avas  a  slight  improvement,  but 
as  yet  no  free  passage  for  the  ear  through  the  tubes.  On  July  7th 
a  sudden  and  great  improvement  took  place  in  the  right  ear,  after 
blowing  the  nose.  Hearing  distance,  six  inches  in  the  right,  and  a 
quarter  of  an  inch  in  the  left  ear.  Cracks  now  occurred  in  both 
ears  from  time  to  time,  and  were  followed  by  great  amelioration  in 
the  hearing.     At  the  end  of  July  he  had  perfectly  recovered. 

Case  III.  Obstruction  at  the  faucial  orifice  from  relaxed  mucous 
membrane  for  two  months  after  influenza. — Miss.  T.,  aged  16,  was 
brought  to  me  on  June  7th,  1853.  She  was  pale,  with  a  weak  pulse, 
and  somewhat  out  of  health,  having  had  an  attack  of  influenza  for 
two  months.     Catamenia  irregular. 

History. — AVlien  a  child,  was  subject  to  dulness  of  hearing  during 
a  cold,  but  recovered  as  soon  as  the  cold  passed  away.  During  the 
recent  attack  of  influenza  has  been  so  dull  of  hearing  as  to  require 
to  be  spoken  to  distinctly  Avithin  the  distance  of  a  yard  ;  general 
conversation  is  not  heard.  Sometimes  during  an  entire  day  hears 
rather  better.     Complains  of  a  ticking  noise  in  the  ears. 

Results  of  examination:  rigid  ear. — Watch  only  heard  on  pres- 
sure ;  membrana  tympani,  surface  dull,  concave ;  Eustachian  tube 
impervious.  Left  ear. — In  the  same  state  as  the  right.  The  mucous 
membrane  of  the  fauces  was  relaxed. 

Treatment. — Considering  that  the  relaxed  condition  of  the  faucial 


THE     EUSTACHIAN     TUBE.  239 

mucous  membrane  was  dependent  upon  the  state  of  the  health,  steel 
was  administered,  and  plans  for  invigorating  the  system  Avere  recom- 
mended :  gentle  counter-irritation  over  the  region  of  the  fauces  Avas 
also  enjoined. 

July  loth. — lias  had  a  "  rumbling"  sound  in  the  ears,  since 
which  she  has  been  better.     Hearing  distance,  tAvo  inches. 

July  20th. — Well.     Eustachian  tubes  pervious. 

ScA'cral  additional  cases  might  be  related,  but  the  three  I  have 
mentioned  will  be  sufficient  to  illustrate  the  nature  of  the  affection. 

((?.)    OBSTRUCTION    OF    THE    EUSTACHIAN    TUBE    AT    THE    TYMPANIC 
ORIFICE    FROM    THICKENED    MUCOUS    MEMBRANE. 

Inasmuch  as  one  of  the  most  common  affections  of  the  ear  is  in- 
flammation of  the  tympanic  mucous  membrane,  it  will  be  readily 
conceived  that  obstruction  of  the  tympanic  orifice  of  the  Eustachian 
tube  is  likely  to  take  place  from  the  same  cause.  It  is  Avell  known 
tluit  the  osseous  portion  of  the  Eustachian  tube,  Avhich  is  about  the 
size  of  an  ordinary  probe,  is  lined  by  an  extremely  thin  mucous 
membrane,  Avhich,  like  that  covering  the  osseous  Avails  of  the  tym- 
panum, adheres  firmly  to  the  surface  of  the  bone,  and  appears  to 
act  in  tlie  tAvofold  capacity  of  a  periosteum  and  mucous  membrane ; 
one  of  the  reasons  for  its  extreme  tenuity  being  the  fact  that  the 
bony  part  of  the  Eustachian  tube  forms  part  of  the  cavity  Avith  re- 
sonant Avails.  The  whole  of  the  mucous  membrane  of  the  Eusta- 
chian tube,  excepting  at  the  tAvo  extremities,  is  so  surrounded  by 
muscles  and  bone  as  to  be  little  liable  to  become  the  seat  of  dis- 
ease. In  making  dissections,  I  have  rarely  found  that  it  has  been 
morbidly  affected ;  indeed,  in  some  cases  of  ulceration  of  the  faucial 
mucous  membrane  in  scarlet  fever,  accompanied  by  ulceration  of 
the  mucous  membrane  of  the  tympanum,  the  membrane  lining  the 
central  portion  of  the  tube  has  been  found  free  froiu  disease.  It 
Avould  thus  appear  that  the  commonly  received  opinion  of  the  ex- 
tension of  the  disease,  by  direct  continuity,  from  the  fauces  to  the 
tympanum,  is  not  ahvays  correct ;  and  from  observation  of  Avhat 
occurs  in  other  cases,  there  is  no  difficulty  in  conceiving  the  affections 
of  the  tAvo  parts  to  originate  at  the  same  time  Avithout  any  relation 
of  cause  and  effect.  It  cannot  be  doubted  that  it  is  very  fortunate 
the  mucous  membrane  of  the  central  part  of  the  tube  is  so  little 
liable  to  become  thickened,  since  it  Avould  of  course  be  very  difficult 
to  act  upon  it  effectually. 


240  THE    DISEASES    OF    THE    EAR. 

The  mucous  membrane  covering  the  bone  which  forms  the  tym- 
panic aperture  of  the  tube  is,  on  tlie  contrary,  liable  to  congestion 
and  hypertrophy,  being,  like  the  mucous  membrane  of  the  tympa- 
num, exposed  to  the  influence  of  the  cold  air  entering  the  meatus 
externus.  Symptoms  arising  from  this  cause  are  usually  present  in 
the  cases  under  consideration  ;  but  there  is  generally  in  addition  a 
great  concavity  of  the  membrana  tympani,  loud  noises  in  the  ears, 
and,  upon  examination,  an  impervious  state  of  the  Eustachian  tube. 

The  Jihtory  of  the  two  cases  differs  in  the  fact,  that  in  cases  of 
obstructed  Eustachian  tube,  the  deafness  generally  comes  on  rapidly, 
often  disappears,  and  as  rapidly  reappears;  whereas  in  those  arising 
from  disease  in  the  mucous  membrane,  the  progress  is  usually  slow 
and  regular.  It  must  also  be  remembered,  that  in  cases  of  obstruc- 
tion of  the  Eustachian  tube  at  the  tympanic  orifice,  there  is  com- 
monly a  history  of  previous  attacks  of  inflammation  in  the  tympanic 
mucous  membrane,  which  is  not  often  the  case  in  instances  of  ob- 
struction at  the  faucial  orifice  :  the  membrana  tympani  also  presents 
appearances  indicative  of  inflammation  having  occurred  in  the  tym- 
panic cavity.  The  most  simple  cases  of  obstruction  of  the  Eusta- 
chian tube  at  the  tympanic  orifice  are  those  following  an  ordinary 
cold,  in  Avhich  a  sense  of  fulness  is  felt  in  the  ears,  often  attended 
with  noises,  and  with  dulness  of  hearing — S3-raptoms  Avhich  last  for 
a  few  days,  and  then  ordinarily  disappear  with  a  sensation  of  some- 
thing bursting  in  the  ear. 

In  the  treatment  of  these  cases,  all  those  measures  should  be  re- 
sorted to  which  will  be  described  as  serviceable  in  hypertrophy  of 
the  mucous  membrane  of  the  tympanum.  In  addition,  the  opera- 
tion of  puncturing  the  membrana  tympani  is  sometimes  advisable. 


ON   THE    OPERATION    OF    PUNCTURING    THE    MEMBRANA   TYMPANI. 

Since  Sir  Astley  Cooper  obtained  a  medal  from  the  Royal  Society, 
on  account  of  the  success  which,  in  a  few  cases,  followed  the  opera- 
tion of  j)uncturing  the  membrana  tympani,  this  operation  has  been 
performed  frequently,  and  in  cases  of  deafness  arising  from  every 
possible  cause.  Though,  doubtless,  in  certain  cases  it  may  be  of 
great  service,  it  is  an  operation  rarely  required,  and  one  which,  if 
not  judiciously  performed,  is  liable  to  produce  the  most  injurious 
consequences.     In  Sir  Astley  Cooper's  successful  cases,  there  was 


THE     EUSTACHIAN    TUBE.  241 

simple  obstruction  of  the  Eustachian  tube  ;  and  there  is  little  doubt 
that  the  affection  Avould  have  yielded  to  simple  measures,  having  for 
their  object  the  removal  of  the  obstruction,  while  the  cure  instead 
of  being  temporary  would  have  been  permanent.  In  the  great 
majority  of  cases  where  Sir  Astley  punctured  the  membrana  tym- 
pani  not  the  slightest  benefit  accrued,  because  the  deafness  was  de- 
pendent upon  other  causes  than  obstruction  of  the  Eustachian  tube; 
and  in  some  cases  of  deafness  from  debility  of  the  auditory  nerve, 
the  shock  of  the  operation  greatly  aggravated  the  symptoms.  In 
what  cases,  then,  should  the  operation  be  performed  ?  It  will  be  ob- 
served that  I  have  not  recommended  it  in  cases  of  obstruction  of  the 
faucial  orifice  of  the  Eustachian  tube,  because  that  obstruction  can 
be  otherwise  removed;  but  should  the  faucial  orifice  be  permanently 
closed  by  adhesion  of  its  walls  (a  case  never  met  with  by  me),  there 
can  be  no  question  that  it  should  be  performed.  It  is  also  called  for 
in  cases  of  stricture  of  the  osseous  portions  of  the  tube,  in  those  of 
obstruction  by  fibrinous  effusion,  and  where  the  thickened  mucous 
membrane  of  the  tympanic  orifice  will  not  yield  to  other  treatment. 
Great  and  immediate  improvement  frequently  follows  the  operation ; 
but  there  is  usually  so  much  difficulty  in  keeping  the  aperture  open, 
that  the  value  of  it  is  much  diminished.  The  ordinary  instrument 
for  performing  the  operation  is  the  sharp  triangular  end  of  a  probe ; 
and  where  only  temporary  effect  is  required,  this  is  sufficient.  Fa- 
brizzi  invented  an  instrument  for  drilling  out  a  circular  portion  of 
the  membrane  ;  but  the  extreme  sensitiveness  of  the  outer  surface 
of  the  membrana  tympani  renders  it  difficult  of  application.  It  con- 
sists of  a  silver  tube,  about  four  inches  long,  one  end  of  which, 
about  a  line  in  diameter,  is  tipped  with  steel  and  made  to  cut ;  the 
opposite  end  is  made  to  screw  on  the  outer  part  of  a  trocar,  near  its 
handle  ;  while  the  trocar,  consisting  of  a  silver  rod,  has  at  its  end  a 
fine  wire  shaped  like  a  corkscrew.  When  used,  the  trocar  is  passed 
through  the  canula,  and  the  spiral  wire  which  projects  beyond  it  has 
its  point  passed  through  the  membrana  tympani,  and  then  turned 
round  so  as  to  cause  it  to  enter  the  tympanic  cavity.  "When  this 
has  been  eflfected,  and  a  firm  hold  of  the  membrana  tympani  is  se- 
cured, the  canula  is  to  be  slightly  unscrewed  ;  an  action  by  which 
its  cutting  extremity  is  pressed  through  the  substance  of  the  mem- 
brana tympani  and  removes  a  circular  portion.  This  instrument 
may  be  used,  however,  in  cases  where  the  sensibility  of  the  tym- 
panic membrane  has  been  impaired  by  disease. 

16 


242  THE    DISEASES    OF    THE     EAR. 

The  usual  method  is,  as  stated,  to  puncture  by  the  probe  :  and 
the  part  best  adapted  for  this  purpose  is  that  between  the  handle  of 
the  malleus  and  the  posterior  margin. 

The  plan  adopted  by  me  for  keeping  open  an  orifice  in  the  mem- 
brana  tympani,  and  the  particulars  of  a  case  in  ■which  it  was  prac- 
tised, will  be  found  below  :  it  consists  in  making  a  triangular  flap, 
by  means  of  a  very  small  scalpel,  the  blade  of  which  is  not  more 
than  two  lines  in  breadth. 

Case  I.  Obstruction  by  thickened  mucous  membrane  at  the  tym- 
p'anic  orifice. — Miss  K.  J.,  aged  10,  was  brouglit  to  me  on  July  14, 
1853. 

History. — Between  five  and  six  years  ago,  after  a  cold,  sufi'ered 
from  an  attack  of  earache,  followed  by  dulness  of  hearing,  so  that 
she  has  been  obliged  to  listen,  in  order  to  hear  conversation. 
During  attacks  of  cold,  she  has  been  so  much  worse  as  to  require 
to  be  spoken  to  distinctly,  within  tlie  distance  of  a  yard  or  two. 
Is  now  subject  to  occasional  attacks  of  earache,  and  has  had  a 
slight  discharge  from  the  right  ear.  On  examination  of  the  right 
ear,  the  dermoid  layer  of  the  membrana  tympani  was  white  and 
thick,  and  covered  with  a  small  quantity  of  discharge  ;  the  mem- 
brana itself  was  more  concave  than  natural ;  and  the  Eustachian 
tube  was  obstructed. 

Left  ear. — The  surface  of  the  meatus  was  covered  with  cerumen, 
having  a  natural  appearance  ;  the  membrana  tympani  was  white 
and  concave ;  the  Eustachian  tube  was  obstructed  ;  and  the  mucous 
membrane  of  the  fauces  Avas  in  a  natural  state. 

Treatment. — Leeches  were  applied  below  each  ear,  twice  a  Aveek, 
followed  by  blisters  ;  and  the  one-thirtieth  of  a  grain  of  the  bichlo- 
ride of  mercury  was  given  twice  daily  ;  a  course  of  treatment  which 
was  pursued  for  six  weeks.  At  first,  there  was  no  improvement ; 
after  three  weeks,  however,  a  slight  diminution  of  the  deafness  took 
place ;  and  on  the  1st  of  September,  the  hearing  was  quite  restored, 
and  the  Eustachian  tubes  were  pervious. 

Case  II.  Obstruction  by  thickened  mucous  membrane  at  the  tym- 
panic orifice,  after  influenza;  jyolypus  in  one  ear,  a  collection  of 
cerumen  in  the  other  ;  great  improvement. — Master  J.  P.  M.,  aged 
14,  in  good  health,  was  brought  from  Lincolnshire,  July  27,  18")3. 

History. — Four  years  ago  he  had  an  attack  of  influenza,  followed 
by  so  conspicuous  a  hardness  of  hearing,  that  he  required  persons 
to  speak  to  him  in  a  loud  voice.     During  a  cold  the  deafness  is  much 


THE     EUSTACHIAN    TUBE.  243 

increased  ;  at  times,  after  a  feeling  of  cracking  in  the  ear,  has  heard 
much  better.  This  crack  occurred  once  in  the  right  ear,  after  bath- 
ing, and  was  followed  by  perfect  hearing  for  a  few  hours.  The  right 
ear  has  discharged  blood  for  several  months,  and  been  affected  with 
earache.  Previous  treatment. — Glycerine  has  been  dropped  into 
both  ears  without  any  benefit ;  slight  improvement  followed  the  use 
of  a  blister  behind  each  ear  ;  tonics  have  been  administered. 

On  examination:  rigid  ear. — Hearing  distance,  half  an  inch;  the 
meatus  contained  a  discharge,  and  at  its  inner  part,  concealing  the 
membrana  tympani,  Avas  a  red,  globular  polypus.  Eustachian  tube 
obstructed.  Left  ear. — Hearing  distance,  half  an  inch  ;  the  meatus 
contained  a  collection  of  cerumen  ;  on  removal  of  which,  the  mem- 
brana tympani  was  seen  to  be  very  concave  and  white :  Eustachian 
tube  obstructed. 

Treatment. — The  polypus  was  extracted  from  the  right  ear  by  the 
lever-ring  forceps ;  vesication  was  kept  up  over  the  mastoid  pro- 
cesses ;  small  doses  of  the  iodide  of  potassium  Avere  administered. 
In  the  course  of  three  months  the  hearing  returned,  and  he  remained 
well. 

Case  III.  Obstruction  of  the  tympanic  orifice  of  the  tube;  polypus 
in  the  right  ear  ;  cured. — Miss  M.,  aged  14,  saw  me  on  the  14th  of 
February,  1854.  Her  health  was  good,  but  she  complained  of  head- 
ache. 

History. — During  the  last  seven  years  has  been,  at  times,  dull  of 
hearing,  and  has  had  attacks  of  earache.  During  a  cold  is  much 
worse.  Has  not  had  any  discharge.  Occasionally,  after  feeling  as 
if  something  had  burst  in  the  right  ear,  had  heard  quite  well  for  a 
short  time.  She  now  has  to  be  loudly  spoken  to  close  to  the  right 
ear  ;  the  left  is  useless.  On  examination.,  the  hearing  distance  of 
the  right  ear  was  found  to  be  two  inches  ;  the  membrana  tympani 
was  concave  and  white  ;  the  Eustachian  tube  obstructed.  With  the 
left  ear,  the  crack  of  the  nails  Avas  heard  ;  the  membrana  tympani 
was  thick ;  the  Eustachian  tube  obstructed. 

Treatment. — Brown's  vesicating  paper  Avas  ordered  to  be  applied 
behind  both  ears  every  night,  and  three  grains  of  hydrargyrum  cum 
creta  Avere  to  be  taken  every  night. 

March  7th. — The  same  :  has  not  been  pursuing  the  treatment  Avitli 
regularity  :  to  take  an  emetic  once  a  Aveek,  and  the  one-thirtieth  of 
a  grain  of  the  bichloride  of  mercury,  twice  daily  ;  the  vesicating 
paper  to  be  continued. 


244  THE     DISEASES     OF     THE     EAR. 

April  0th. — Has  heard  well  for  a  week,  and  hears  better  to-day 
than  on  March  7th.  A  small  vascular  polypus  is  seen  in  the  right 
meatus  near  the  membrana  tympani. 

Mav  11th. — The  right  ear  has  greatly  improved  ;  hearing  distance 
nine  inches.     Left  ear  :  watch  heard  on  pressure. 

June  14th. — Right  ear  cured :  the  polypus  has  disappeared. 

Case  IV.  Obstruction  of  the  tympanic  orifice  of  the  tube  ;  tempo- 
rary relief  by  puncturing  the  membj'ana  tympani  ;  cured  by  removing 
the  obstruction. — J.  R.,  Esq.,  aged  53,  strong,  and  in  good  health, 
was  sent  to  me  by  Mr.  Cock,  on  May  7th,  1853. 

History. — When  a  boy,  was  deaf,  and  was  taken  to  Sir  Astley 
Cooper,  who  punctured  the  drum  of  each  ear  ;  which  operation  was 
followed  by  complete  relief  until  eight  years  ago,  when,  after  a  vio- 
lent cold,  deafness  gradually  came  on  in  both  cars ;  and  has  remained 
till  now,  with  the  exception  of  a  day  or  two's  improvement,  at  times, 
after  violent  sneezing.  At  present,  he  has  to  be  loudly  spoken  to 
within  a  foot  of  his  head,  in  which  there  is  a  feeling  of  constriction 
and  of  pressure  on  the  top  part.  On  examination  of  right  ear,  the 
crack  of  the  nails  only  is  heard  ;  the  membrana  tympani  is  very 
opar^ue,  uneven,  and  concave  ;  Eustachian  tube  obstructed.  Left 
ear. — Watch  heard  on  pressure.  Membrana  tympani  and  Eusta- 
chian tube  in  the  same  state  as  in  the  right  ear. 

There  was  no  doubt  in  my  mind  that  the  cause  of  the  deafness 
was  a  thickened  state  of  the  mucous  membrane  at  the  tympanic  ori- 
fice of  the  tube  ;  and  I  prescribed  the  application  of  leeches  below 
the  ear,  to  be  followed  by  blisters,  while  small  doses  of  mercury 
were  to  be  administered.  The  patient,  however,  implored  me,  if 
possible,  to  render  him  some  immediate  relief,  as  he  was  a  candi- 
date for  a  public  appointment ;  for,  although  my  assurance  that  he 
would  recover  might  favorably  influence  the  committee,  before  whom 
he  was  to  appear  the  following  day,  still  he  greatly  feared  that, 
should  he  not  hear  what  was  said,  he  might  be  rejected.  I,  there- 
fore, but  unsuccessfully,  attempted  to  pass  air  into  the  tympanum 
through  the  catheter.  I  then  punctured  each  membrana  tympani 
with  an  ordinary  probe,  which,  as  it  passed,  conveyed  the  feeling  of 
the  membrane  being  soft  and  flaccid.  The  result  Avas  an  instanta- 
neous return  of  the  hearing  power,  and  the  total  disappearance  of 
the  weight  in  the  head :  to  use  his  own  words,  he  "  felt  free  again." 
The  hearing  distance  of  each  ear  was  six  inches." 

May  30th. — After  the  operation,  continued  to  hear  well  until  a 


THE    EUSTACHIAN    TUBE.  245 

few  (lays  ago,  when  the  deafness  slowly  returned,  and  he  is  now 
nearly  as  deaf  as  on  the  14th.  The  orifice  in  each  niembrana  tym- 
pani  had  closed.  As  he  was  unable  to  wait  until  the  remedies  for 
opening  the  tube  could  be  tried,  I  made  a  triangular  flap,  about  two 
lines  long,  and  a  line  broad  below,  in  each  membrane,  by  means  of 
a  scalpel,  the  blade  of  Avhich  was  about  two  lines  in  breadth :  the 
apex  of  the  flap  was  above,  and  it  was  turned  down.  The  result 
was  as  instantaneously  favorable  as  in  the  previous  operation :  and 
as  it  was  considered  probable  that  the  aperture  would  close,  active 
treatment  for  the  purpose  of  opening  the  tube  was  at  once  carried 
out.  The  consequence  was,  that  in  a  fortnight,  although  the  orifice 
in  each  membrana  tympani  had  closed,  the  air  passed  freely  through 
the  Eustachian  tube,  and  the  patient  heard  well. 

Closure  of  the  tympanic  orifice  of  the  Eustachian  tube  by  the  effu- 
sion of  fibrine  will  be  spoken  of  when  describing  cases  of  the  effusion 
of  fibrine  into  the  tympanic  cavity. 


{d.)  OBSTRUCTION  OF  THE  MIDDLE  PART  OF  THE  EUSTACHIAN  TUBE; 
BY  A  COLLECTION  OF  MUCUS,  BY  A  STRICTURE  OF  ITS  CARTILA- 
GINOUS OR  OSSEOUS  PORTIONS,  OR  BY  BANDS  OF  ADHESION  CON- 
NECTING  THE    WALLS. 

In  the  tabular  view  giving  the  result  of  1523  dissections,  it  will 
have  been  observed  that  in  thirteen  instances  the  Eustachian  tube 
contained  mucus.  In  my  opinion,  however,  a  collection  of  mucus 
rarely  offers  insuperable  resistance  to  the  action  of  the  muscles  of 
the  tube,  to  the  pressure  of  the  air  in  the  fauces  during  the  act  of 
deglutition,  or  to  an  attempt  at  a  forcible  respiration,  with  closed 
nostrils,  &c.  It  is  nevertheless  possible  that  in  some  of  the  cases 
where  the  tympanic  orifice  of  the  tube  is  closed  by  thick  mucous 
membrane,  there  may  be  also  an  accumulation  of  mucus :  but  as  its 
presence  would  not  require  any  alteration  in  the  treatment,  it  is  un- 
necessary to  dilate  upon  the  subject. 

Stricture  of  the  osseous  j^ortion  of  the  Eustachian  tube  is  very 
rare.  Only  one  case  has  fallen  under  ray  observation ;  .but  as  I  had 
the  opportunity  of  seeing  the  patient  during  life,  and  afterwards  of 
making  a  dissection  of  the  ear,  it  is  of  sufficient  interest  to  be  de- 
tailed at  length. 

Casel.  Stricture  of  the  osseous  portion  of  the  Eustachian  tube; 


246  THE     DISEASES    OF    THE     EAR. 

dissect  I  on. — C.  J.,  aged  45,  was  visited  by  me  in  the  month  of 
November,  1840.  He  was  dying  from  tubercular  disease,  so  that  I 
was  precluded  from  making  so  minute  an  examination  as  would  have 
been  desirable.  The  history  of  the  origin  and  progress  of  the  deaf- 
ness, as  far  as  could  be  ascertained,  was  as  follows  : — About  twenty 
years  ago,  the  patient  suffered  from  a  violent  inflammation  in  the 
right  ear,  followed  by  a  discharge  from  the  external  meatus,  which 
had  continued  almost  without  intermission  up  to  the  time  he  was 
seen  by  me.  For  a  considerable  period  this  ear  had  been  unable  to 
distinguish  sounds,  and  the  left  ear  had  been  gradually  growing  less 
and  less  sensitive  to  sonorous  vibrations  during  the  preceding  six  or 
seven  years.  No  pain  had  been  felt  in  it,  however,  and  there  had 
been  no  discharge  from  the  external  meatus. 

Upon  inspection  by  means  of  a  speculum  and  lamp,  the  membrana 
tympani  of  the  right  ear  was  observed  to  be  absent,  while  the  mucous 
membrane  lining  the  tympanic  cavity  was  very  thick,  and  covered 
by  a  large  quantity  of  purulent  matter.  In  the  left  ear,  the  lining 
membrane  of  the  external  ear  was  slightly  reddened,  and  the  mem- 
brana tympani  Avas  as  white  as  writing  paper ;  while  the  handle  of 
the  malleus,  usually  so  distinctly  seen,  could  not  be  distinguished 
from  the  surrounding  membrane.  Towards  its  centre,  the  surface 
of  the  mem])rana  tympani  had  lost  the  natural  shining  appearance  ; 
but  a  small  portion  of  its  surface,  on  each  side  of  the  handle  of  the 
malleus,  although  perfectly  white,  was  so  smooth  as  to  reflect  the 
light  of  the  lamp.  As  the  patient  was  in  a  state  of  great  debility, 
the  otoscope  was  not  applied  to  either  ear  to  test  the  condition  of 
the  Eustachian  tube.  The  patient  died  a  few  days  after  the  exami- 
nation. 

Post-mortem  inspection.  liight  car. — The  mucous  membrane 
lining  the  tympanic  cavity  was  thick  and  in  parts  ulcerated ;  wliile 
the  bone  forming  the  upper  wall  of  the  cavity,  with  which  the  ulcer- 
ated membrane  was  in  contact,  was  carious.  The  Eustachian  tube 
was  healthy. 

Left  ear. — The  central  portion  of  the  membrana  tympani  was 
found  to  be  white  and  thick  ;  but  those  parts  of  it  whicii  lie  ante- 
riorly and  ]K)steriorly  to  the  handle  of  the  malleus,  were  soft  and 
attenuated,  and  the  white  appearance  was  due  to  the  presence  of 
mucus  in  the  tympanic  cavity,  in  immediate  contact  with  the  inner 
surface  of  the  membrana  tympani.  So  softened  Avas  this  portion  of 
that  membrane,  that  on   applying  the  slightest  pressure,  the  fibres 


THE    EUSTACHIAN    TUBE. 


247 


composing  it  gave  way,  and  three  small  orifices  were  produced. 
The  cavity  of  the  tympanum  and  the  mastoid  cells  were  filled  with 
thick,  white  mucus,  and  no  air  was  discoverable.  The  mucous 
membrane  lining  the  cavity  was  also  thicker  than  natural. 

Tlic  Eustacliian  tube. — The  internal  portion  for  the  length  of 
half  an  inch  was  healthy  ;  but  at  about  that  distance  from  the  cavity 
of  the  tympanum,  there  was  a  sudden  constriction,  and  for  the 
length  of  about  a  line  and  a  half  tlie  tube  was  so  contracted,  that, 
even  when  its  superior  wall  was  removed,  it  was  with  difficulty  that 
an   ordinary   sized  bristle   could  be   introduced  into   the   opening. 


Fig.  81. 


stricture  of  the  Eustachian  Tube.     The  black  bristle  is  seen  passing  from  the  tympanic 
cavity  through  the  strictured  portion. 


This  stricture  resulted  from  the  external  and  internal  walls  of  the 
tube  pressing  against  each  other ;  the  small  space  still  permeable 
being  at  the  upper  part.  The  more  remote  cause  of  the  stricture 
would  appear,  however,  to  have  been  an  enlargement  of  portions  of 
the  bone  constituting  the  external  and  internal  osseous  walls  of  the 
tube :  the  former  being  at  this  part  twice  its  natural  thickness,  and 
somcAvhat  rough,  Avhile  the  latter  was  forced  outwards  by  the  dilata- 
tion of  the  carotid  canal,  which,  pressing  thus  upon  the  cartilaginous 
portion  of  the  Eustachian  tube  with  -which  it  was  in  contact,  pro- 
duced a  flattening  of  the  natural  concavit}^  of  the  internal  wall. 
The  mucous  membrane  lining  the  Eustachian  tube  was  in  a  natural 
state. 

Although  three  dissections  are  recorded'  of  adhesion  between  the 
walls  of  the  tube  by  means  of  membranous  bands,  I  have  not  hitherto 
met  with  a  case  during;  life.  In  such  an  instance  the  treatment 
would  consist  in  puncturing  the  membrana  tympani,  and  establish- 
ing an  orifice  in  it. 


CHAPTER  XII. 

THE  CAVITY  OF  THE  TYMPANUM. 

ANATOMICAL  OBSERVATIONS  —  PATHOLOGICAL  OBSERVATIONS  —  DISEASES  OF  THE 
IIUCOUS  MEMBRANE  : — a,  CONGESTION.  b,  ACUTE  INFLAMMATION — AFFECTING  THE 
PORTIA  DURA  NERVE — EXTENDING  TO  THE  BRAIN — SCROFULOUS  MATTER  IN  THE 
TYMPANIC  CAVITY.  C,  CHRONIC  INFLAMMATION.  fl,  CHRONIC  CATARRHAL  INFLAM- 
MATION, e,  CHRONIC  CATARRHAL  INFLAMMATION  EXTENDING  TO  THE  BONE,  DURA 
MATEU,    on    BRAIN.     /,    ULCERATION    OF    THE    MUCOUS    MEMBRANE. 

Anatomical  Observations. — The  tympanic  cavity  is  lined  through- 
out by  a  fine  membrane,  -which  forms  the  internal  layer  of  the 
membrana  tympani,  and  from  which  it  can  sometimes  be  detached 
without  difficulty.  Internally  it  covers  the  surface  of  the  pro- 
montory and  the  membrana  propria  of  the  fenestra  rotunda ;  it  is 
reflected  from  the  promontory  at  the  circumference  of  the  fenestra 
ovalis  upon  the  surface  of  the  stapes,  and  it  envelopes  the  incus 
and  malleus,  by  means  of  which  it  is  continuous  with  the  inner 
layer  of  the  membrana  tympani ;  above  and  below  that  membrane 
it  covers  the  osseous  walls  of  the  tympanum,  and  is  prolonged 
posteriorly  into  the  mastoid  cells,  while  anteriorly  it  is  con- 
tinuous with  the  lininji  membrane  of  the  Eustachian  tube.  The 
mucous  meml)rane  of  the  tympanic  cavity,  in  a  healthy  ear,  is 
so  extremely  thin  as  to  be  (^uite  transparent ;  and  its  presence 
upon  the  surface  of  the  osseous  walls  and  ossicles  of  the  tympanum, 
can  often  only  be  detected  by  the  use  of  a  magnifying-glass  and  by 
the  touch.  In  a  natural  state  the  nervous  filaments  upon  the  sur- 
face of  the  promontory  are  very  distinctly  seen,  the  margin  of  the 
fenestra  rotunda  is  defined  and  regular,  and  the  membrane  which 
occupies  it  is  thin  and  transparent.  The  crura  of  the  stapes,  as 
well  as  their  point  of  connection  with  the  base,  are  clearly  seen, 
and  a  distinct  fissure  is  observable  between  the  inferior  surface  of 
the  crura   and  the  ])romontory.     The  quantity  of  mucus  covering 


THE     CAVITY    OF    THE    TYMPANUM. 


249 


this  membrane  in  :i  healthy  ear  is  so  small  as  to  be  scarcely  per- 
ceptible. The  membrane  itself  is  composed  of  extremely  fine  and 
delicate  fibres,  and  it  has  a  strong  analogy  "with  the  serous  mem- 
branes :  first,  in  respect  to  its  extreme  tenuity  and  great  smoothness ; 
second,  in  the  frequency  "vvith  Avhich  membranous  bands  connect 
together  various  parts  of  the  tympanic  cavity.  Over  its  surface 
extends  a  layer  of  very  minute  epithelial  cells,  some  of  -which  are 
ciliated.  The  supply  of  bloodvessels  is  abundant,  though  they  are 
so  minute  as  not  to  be  discernible,  except  when  distended  with 
blood :  this  happens  in  disease,  and  then  they  are  often  very  much 
dilated  and  surcharged.  In  young  persons  the  membrane  is  highly 
vascular,  and,  when  successfully  injected,  is  found  to  be  pervaded 
by  plexiform  ramifications.  Beneath  the  mucous  membrane  lie 
the  branches  of  the  tympanic  nerve  from  the  glosso-pharyngeal. 

The  upper  wall  of  the  tympanum  is  formed  by  a  layer  of  bone 
Avhich  separates  the  tympanic  cavity  from  that  of  the  cerebrum, 
and  which  deserves  special  attention,  inasmuch  as  the  diseases  of 
the  tympanum,  Avhich  affect  the  brain,  usually  advances  through 
that  bone.     Its  form  is  an  elongated  oval,  and  it  measures  about 

Fig.  82. 


An  antero-posterior  vertical  section  of  the  Temporal  Bone  through  the  Tympanic  Cavity 

and  Mastoid  Cells. 


three-quarters  of  an  inch  long  and  from  a  quarter  to  half  an  inch 
in  breadth.  Its  direction  is  obliquely  inwards  and  forwards,  like 
that  of  the  petrous  bone.  Externally  it  is  attached  to  the  lower 
part  of  the  scjuamous,  and  internally  to  the  outer  part  of  the 
petrous,  bone :  anteriorly  it   is    continuous    with    the    roof  of  the 


250 


THE     DISEASES    OF    THE    EAR. 


Eustachian  tul)c,  ami  posteriorly  with  the  roof  of  the  horizontal 
portion  of  tlic  mastoid  cells.  This  osseous  lamina,  forming  the 
upper  wall  of  the  tympanum,  varies  iinuli  in  thickness,  being  in 
some  instances  from  half  to  an  entire  line  thick,  though  more 
frequently  it  is  very  thin,  presenting  a  mere  shell  of  translucent 
bone.  In  many  specimens  this  lamina  is  deficient  in  parts,  and 
the  mucous  membrane  of  the  tympanum  is  in  contact  with  the  dura 
mater  covering  the  petrous  bone.  In  some  specimens  in  my  pos- 
session, the  head  of  the  malleus  projects  through  an  orifice  in  this 
portion  of  the  bone,  and  was  directly  covered  by  the  dura  mater. 
This  defect  in  the  upper  wall  of  the  tympanum  is  not  usually  the 
result  of  disease,  but  of  the  process  of  development.  In  the 
specimen,   of  which    the    following  is   a   representation,  the  hori- 

FiG.  83. 


The  upper  Osseous  Wall  of  the  Tympanum  defective. 


zontal    lamina    alone    is  absent,  wliilc'  the   vertical   septa   extend 
upwards,  even  above  the  surrounding  surface. 

It  has  been  thought  desirable  to  be  thus  particular  in  the  descrip- 
tion of  the  relations  of  the  tyinpannm,  because  fre([uent  reference 


THE     CAVITY     OF     THE     TYMPANUM.  251 

is  made  to  the  description  in  the  pathological  details  subsequently 
entered  into. 

Pathological  observations. — Tlie  diseases  of  the  tympanic  cavity 
are  numerous  and  important.  Perhaps  the  most  common  affection 
to  which  the  organ  of  hearing  is  subject,  is  a  greater  or  less  degree 
of  thickening  of  the  tympanic  mucous  membrane,  with  or  without 
catarrh  through  the  membrani  tympani.  Besides  this  affection,  a 
simple  accumulation  of  mucus  in  the  tympanic  cavity  is  of  great 
frequency;  and,  finally,  anchylosis  of  the  stapes  to  the  fenestra 
ovalis  is  a  most  common  disease. 

The  diseases  of  the  tympanic  cavity,  as  revealed  by  the  dissection 
of  1013  diseased  ears,  are  as  follow : — 

CONTEXTS. 

Mucus,    ..............  65 

Blood, 6 

Blood  and  niucu.s,            ...........  1 

Blood,  mucus,  and  lymph, 1 

Serum,             .............  10 

Serum  and  mucus, 3 

Serum  and  lymph,           ...........  1 

Lymph,             .............  6 

Epithelium,     .............  2 

Epithelium  and  oil,          .         .                   ........  1 

Scrofulous  matter,           ...........  20 

Calcareous  matter,           ...........  8 

Cerumen,         ..,,,.......•  1 

Cholesterine,            ,          ...........  1 

Cholesterine  and  mucus,          ..........  5 

Cellular  tissue,        ............  2 

Oily  matter,    .............  1 

Pus, 17 

STATE  OF  THK  MUCOUS  MEMBKAXK. 

More  vascular  than  natural,   ..........  75 

Thicker  than  natural,     ...........  211 

Thick  and  very  vascular,          ..........  16 

So  thick  as  to  conceal  the  stapes,    .........  27 

So  thick  as  to  fill  the  tympanic  cavity,    ........  6 

Ulcerated 24 

Pulpy 5 

Containing  black  pigment  cells,      .........  2 

Having  serum  beneath  it,        ..........  1 

MEMBRANOUS    HANDS    BETWEEN. 

Malleus  and  promontory,         ..........       6 

Malleus,  incus,  and  promontory,     .........       1 


252 


THE     DISEASES    OF    THE    EAR. 


Malleus  and  stapes, 

Malleus,  stapes,  and  promontory,   ..... 

Incus  and  promontory, 

Incus,  stapes,  and  promontory,       ..... 

Incus  and  malleus,  ....... 

Stapes  and  promontory,  the  mucous  membrane  being  healthy 
Stapes  and  promontory,  the  mucous  membrane  being  thick. 
Stapes  and  promontory,  the  mucous  membrane  being  vascula 
Stapes,  promontory,  and  pyramid,  ..... 

All  the  ossicles,        ........ 

All  the  ossicles  and  the  promontory,        .... 

Tensor  tyrapani  muscle  (the  tendon)  and  the  stapes, 
Chorda  tympani  nerve,  incus,  stapes,  and  promontory,   . 
Chorda  tympani  nerve  and  upper  wall  of  tympanum, 


3 

1 

79 

48 

6 

1 

30 

9 

3 

2 

1 


MALLEUS. 


Adherent  to  the  promontory,  ........ 

Absent,  apparently  from  caries  or  ulceration,  .... 

Partly  removed  by  caries,        ........ 

Malleus  and  incus  lying  in  the  mastoid  cells,  ..... 

Fi.xed  by  ligamentous  anchylosis  to  the  upper  wall  of  the  tympanum, 
Fixed  by  osseous  anchylosis  to  the  upper  wall  of  the  tympanum,    . 
The  body  anchylosed  to  the  incus,  ..... 

The  long  process  detached  from  the  membrana  typipani. 
The  long  process  fractured,      .... 

The  long  process  in  contact  with  the  promontory, 
The  long  process  adherent  to  the  incus,   . 
The  long  process  detached  from  the  body, 
The  long  process  absent,  .... 

The  long  process  carious,         .... 

The  long  process  exostosed,     .         .         .         . 


Absent, 4 

Long  process  absent,       ...........  2 

Partly  removed  by  caries,        ..........  8 

Disconnected  from  stapes,        ..........  14 

Disconnected  from  stapes  and  malleus,    ........  1 

Fixed  by  membranous  anchylosis  to  the  orifice  of  the  mastoid  cells,       .         .  2 


The  base  anchylosed  by  bone  to  the  fenestra  ovalis,         .         .         .         .         .49 

The  base  anchylosed  by  bone  to  the  fenestra  ovalis,  the  base  being  expanded,  6 

The  base  anchylosed  by  membrane  to  the  margin  of  the  fenestra  ovalis,         .  36 
The  base  anchylosed  by  membrane  to  the  margin  of  the  fenestra  ovalis,  the 

base  being  exjianded,        ..........  6 

The  base  anchylosed  by  membrane  to  the  margin  of  the  fenestra  ovalis,  an 

exostosis  surrounding  the  fenestra,  ........  2 

The  base  of  the  stapes  attached  to  the  fenestra  ovalis  more  rigidly  than  natu- 
ral   06 


THE  CAVITY  OF  THE  TYMPANUM. 


253 


The  base  projecting  into  the  cavity  of  the  vestibule, 
The  base  expanded  and  more  fixed  than  natural,    . 
The  base  expanded  and  projecting  into  the  vestibule, 
Detached  from  incus  and  attached  to  the  membrana  tynipani 
Anchylosed  to  incus,       ....... 

Detached  from  the  fenestra  ovalis  and  the  incus,     . 
Disconnected  from  the  fenestra  ovalis,     .... 

Partially  absorbed,  ....... 

Atrophied,       ......... 

Absent,  apparently  from  ulceration,        .... 


A1,I,   THE    OS.SICLES. 

Less  movable  than  natural,      ..........  4- 

Absent,  apparently  from  ulceration,        ........  2 

Disconnected  from  each  other,  .........  1 

Carious,  .............  2 


OSSKOUS    WALLS. 


Thickened, 
Carious,  . 


Upper  wall  partly  deficient,     ..........  54 

Lower  wall  partly  deficient,     ..........  25 

Osseous  lamina  between  mastoid  cells  and  lateral  sinus  incomplete,         .         .  2 

Osseous  lamina  between  mastoid  cells  and  cavitas  cerebelli  incomplete,  .         .  1 

Canal  for  portio  dura  nerve  incomplete,           .......  2 

Carotid  canal  contracted,        ..........  7 

Upon  reference  to  Mr.  Hinton's  valuable  paper  on  the  Pathology 
of  the  Ear,  published  in  the  thirty-ninth  volume  of  the  "  Medico- 
Chirurgical  Transactions,"  it  will  be  found  that  the  results  at  which 
he  has  arrived  agree  with  those  quoted  above. 

The  plan  I  purpose  to  follow  in  investigating  the  subject  will  be 
to  consider  successively  the  affections  of  the  mucous  membranes, 
and  those  of  the  ossicles. 


(a.)    CONGESTION    OF   THE    MUCOUS    MEMBRANE    OF   THE   TYMPANUM. 

Congestion  of  the  tympanic  mucous  membrane  usually  follows  a 
cold,  or  an  attack  of  influenza.  The  symptoms  are  a  feeling  of  dead- 
ness  in  the  ears,  sounds  like  the  ringing  of  bells,  dulness  of  hearing, 
and  not  unfrequently  slight  pain.  If  neglected,  this  affection  is 
liable  to  advance  to  acute  inflammation.  It  frequently  accompanies 
conjrestion  of  the  mucous  membrane  of  the  fauces  and  of  the  Eusta- 
chian  tubes.  On  examination,  the  surface  of  the  membrana  tympani 
is  sometimes  observed  to  be  very  shining,  and  in  other  cases  opaque. 


254  THE     DISEASES     OF     THE     EAR. 

The  hearing  power  is  but  slightly  Jiminished.  The  treatment  con- 
sists in  applying  leeches  below  the  ears,  and  using  gentle  counter- 
irritation  over  the  mastoid  processes.  The  symptoms  commonly 
yield  in  a  few  days. 

Case  I. — Mrs.  B.,  ?et.  40,  was  sent  to  me  by  a  medical  man  in 
1853.     She  enjoyed  good  health. 

History. — Has  not  suffered  from  any  affection  of  the  ears  imtil  a 
fortnight  since,  when,, subsequently  to  an  attack  of  cold,  a  feeling 
of  numbness,  and  a  sound  as  of  the  ringing  of  bells,  supervened  in 
both  ears.  There  was  also,  at  times,  a  shooting  pain  in  the  right 
ear.  On  examination^  the  mucous  membrane  of  the  fauces  was  ob- 
served to  be  red. 

Riglit  ear. — The  membrana  tympani  was  rather  more  opaque  than 
natural ;  the  hearing  power  natural ;  the  Eustachian  tube  pervious. 

Left  ear. — Membrana  tymjjani  opaque ;  hearing  distance  three 
inches ;  Eustachian  tube  pervious. 

Treatment. — Slight  counter-irritation,  by  means  of  a  stimulating 
liniment,  was  kept  up  over  and  around  each  ear,  and  in  the  course 
of  ten  days  the  symptoms  were  wholly  removed. 

Case  II. — Mrs.  P.,  iet.  73,  consulted  me  in  July,  1853. 

History. — Six  weeks  previously  had  an  attack  of  influenza,  which 
was  succeeded  by  considerable  pain  in  the  right  ear,  followed  by  a 
sensation  of  "pumping"  in  the  ear,  which  has  continued  to  the  pre- 
sent time :  recently  deafness  of  that  ear  has  been  complained  of, 
and  the  voice  appears  to  come  out  of  the  ear. 

On  examination,  the  membrana  tympani  and  Eustachian  tube 
appeared  to  be  normal ;  but  the  hearing  power  was  so  diminished 
that  the  watch  was  heard  only  when  pressed  upon  the  car. 

Treatment. — A  leech  was  applied  below  the  ear,  and  the  symp- 
toms abated;  counter-irritation  was  then  resorted  to,  and  by  degrees 
all  unpleasant  sensations  vanished. 


{b.)    ACUTE    INFLAMMATION    OF    THE    MUCOUS    MEMBRANE    OF    THE 

TYMPANUM. 

I  have  not  hitherto  been  enabled  to  distinguish  between  acute  in- 
flammation of  the  mucous  membrane  of  the  tympanum  and  that  of 
its  fibrous  membrane,  the  periosteum,  which  is  subjacent  to  it. 
Wlien  the  delicacy  of  these  membranes  is  taken  into  consideration, 


THE    CAVITY     OF    THE    TYMPANUM.  255 

and  tlieir  intimate  union  so  as  to  form  one  membrane  of  sucli  ex- 
treme tenuity  that  its  presence  in  the  healthy  ear  can  only  be  de- 
tected by  the  closest  examination,  it  ■would  be  a  source  of  surprise 
if  acute  inflammation  were  to  attack  either  of  these  structures  Avith- 
out  involving  the  otlicr ;  although  in  many  cases  doubtless  one  of 
them  is  more  specially  implicated.  In  the  description  of  acute  in- 
flammation of  the  mucous  membrane  of  the  tympanum,  the  perios- 
teum -will  therefore  be  included  by  me,  especially  as  the  symptoms 
to  be  detailed  appear  to  indicate  that  the  view  just  advanced  is  cor- 
rect. If  the  mucous  membrane  of  the  tympanum  be  examine<l 
during  an  attack  of  acute  inflammation,  an  opportunity  for  •which  is 
sometimes  afforded  when  a  patient  suffering  from  this  affection  dies 
of  some  other  disease,  the  bloodvessels  are  so  large  and  so  nume- 
rous, that  upon  a  cursory  inspection  the  membrane  seems  as  if  it 
were  covered  by  a  layer  of  dark-colored  blood.  On  more  accurate 
inspection,  however,  it  is  observed  that  this  blood  is  confined  to  the 
cavity  of  the  vessels,  and  that  the  latter  are  completely  distended 
in  every  part. 

The  exciting  cause  is  usually  exposure  to  a  draught  of  cold  air, 
or  sudden  change  of  temperature.  In  its  milder  form  this  affection 
is  met  with  in  children,  and  known  as  earache ;  for  although  the 
paroxysms  of  pain  are  often  very  severe,  the  symptoms  are  generally 
confined  to  the  ear,  and  do  not  produce  much  constitutional  disturb- 
ance. In  children  it  is  evident  that  the  mucous  membrane  is  more 
affected  than  the  periosteum  ;  and  perhaps  one  cause  of  the  compa- 
rative mildness  of  the  affection  in  the  young,  is,  that  the  tympanic 
fibro-mucous  membrane  is  laxer  and  more  extensible  than  in  the 
adult. 

In  children  attacks  of  acute  inflammation  of  the  mucous  mem- 
brane of  the  tympanum  are  apt  to  be  greatly  neglected,  and  conse- 
quently they  frequently  recur  in  the  same  child  ;  and  even  if  they 
do  not  at  the  time  produce  a  serious  lesion  of  the  membrana  tym- 
pani  or  obstruction  of  the  Eustachian  tube,  they  prol)al)ly  lay  the 
foundation  of  deafness  in  after  life,  by  causing  a  permanent  thicken- 
ing and  rigidity  of  the  membrane  :  membranous  anchylosis  of  the 
stapes  seems  also  to  originate  in  this  manner.  When  called  to  see 
a  child  suffering  from  inflammation  of  this  membrane,  a  medical 
man  will  generally  find  that  the  membrana  tympani  is  very  smooth 
and  shining,  and  more  or  less  red  in  color,  according  to  the  degree 
of  distension  with  blood  of  the  vessels  of  the  mucous  membrane 


256  THE    DISEASES    OFTUE     EAR. 

forming  its  inner  layer.  Sometimes  this  latter  membrane  lias  be- 
come thickened,  giving  a  sodden  appearance  to  the  membrana  tym- 
pani ;  a  condition  liable  to  occur  also  when  the  tympanic  cavity 
contains  an  accumulation  of  mucus.  It  commonly  happens  that  in 
children  the  chief  pain  is  felt  at  night,  when  the  recumbent  position 
and  the  heat  of  the  pillow  favor  the  congestion  of  the  membrane. 
Although  the  child  may  not  complain  of  pain  in  the  daytime,  and 
when  seen  by  the  surgeon  may  even  be  cheerful,  still,  should  any 
appearance  of  congestion  remain,  or,  tested  by  the  watch,  any  dul- 
ness  of  hearing,  it  is  important  to  apply  one  or  two  leeches  below 
the  ear,  and  to  keep  up  a  slight  discharge  behind  it. 

Ill  the  adult,  this  affection  is  usually  of  a  much  more  formidable 
nature,  and  it  sometimes  has  a  rheumatic  or  gouty  character.  The 
first  symptom  is  a  sense  of  uneasiness  in  the  ear,  Avhich  becomes  pain 
during  motion,  pressure  on  the  organ,  the  act  of  deglutition,  or  the 
use  of  the  pocket-handkerchief.  This  uneasiness  soon  amounts  to 
continuous  pain,  which,  in  severe  cases,  rapidly  increases  until  it  be- 
comes so  intense  as  to  be  scarcely  endurable  ;  and  extends  over  the 
mastoid  process,  the  whole  of  the  affected  side  of  the  head,  down  the 
neck,  and  into  the  fauces.  The  power  of  hearing  rapidly  diminishes, 
and  a  variety  of  the  most  horrible  sounds  are  experienced  ;  some- 
times described  as  like  the  hissing  and  puffing  of  a  steam-engine, 
varied  by  others  like  a  series  of  explosions  in  the  ear,  or  the  ringing 
of  bells.  A  symptom  of  this  affection  Avhich  adds  greatly  to  the  suf- 
fering of  the  patient,  is  the  impairment  of  the  functions  of  the  brain  ; 
sometimes  amounting  only  to  a  confusion  of  ideas,  frequently  accom- 
panied by  extreme  fear  and  depression  of  the  nervous  system,  caus- 
ing the  worst  forebodings  as  to  the  result  of  the  attack  ;  in  other 
cases  delirium  supervenes,  and  in  the  most  formidable  cases  death 
takes  place,  from  the  inflammation  extending  to  the  membranes  of 
the  brain.  Where  only  some  of  these  symptoms,  and  those  of  a  less 
violent  character  are  present,  the  surgeon  may  doubt  whether  the 
affection  is  in  the  tympanic  cavity  or  in  the  meatus.  An  examina- 
tion of  the  ear  with  the  speculum  and  lamp  will  decide  the  ques- 
tion ;  for  in  the  affection  under  consideration,  there  is  no  appear- 
ance of  inflammation  in  the  dermoid  meatus  or  in  the  membrana 
t3'mpani.  The  modes  in  which  this  affection  terminates  are  the  for- 
mation of  lymph  ;  the  effusion  of  serum  into  the  tympanic  cavity, 
which  escapes  through  the  Eustachian  tube  into  the  fauces ;  or  a 
copious  secretion  of  pus  or  mucus,  which  distends  the  tympanum. 


THE    CAVITY    OF    THE    TYMPANUM.  257 

causes  ulceration  and  perforation  of  all  the  lamina;  of  the  membrana 
tympani,  and  ends  in  abundant  discharge.     In  some  cases  there  is 
no  indication  of  any  secretion  occurring  in  the  tympanum,  and  the 
affection  seems  to  terminate  by  resolution  ;  in  others,  the  dermoid 
meatus  pours  out  a  sympathetic  discharge  without  the  presence  of 
any  orifice  in  the  membrana  tympani.     The  prognosis  in  cases  of 
this  disease  is  favorable,  and  it  is  a  great  consolation  to  the  patient 
to  be  assured,  amidst  the  very  distressing  symptoms  from  which  he 
suffers,  that  no  permanent  injury  need  be  apprehended.     It  would 
appear  that  a  single  attack  of  inflammation  of  the  fibro-mucous  mem- 
brane of  the  tympanum,  however  violent  it  may  be,  does  not  leave 
behind  it  that  rigidity  and  duhiess  of  hearing  Avhich  is  a  sequence  of 
the  attacks  of  a  milder  cliaracter  occurring  in  children.     When  an 
orifice  forms  in  the  membrana  tympani,  it  usually  closes  without 
difiiculty  ;  and  the  power  of  hearing  is  in  two  or  three  weeks  com- 
pletely restored.     In  some,  but  fortunately  rare  cases,  the  inflam- 
mation extends  to  the  petrous  bone,  and  thence  to  the  membrane  of 
the  brain,  causing  death.     It  not  unfrequently  happens,  however, 
that  the  inflammation  extends  to  the  portio  dura  nerve  in  the  aque- 
duct of  Fallopius,  and  partial  or  complete  paralysis  of  that  nerve  is 
the  result  ;  which  is  removed  as  soon  as  the  inflammation  has  wholly 
subsided. 

The  treatment  of  this  affection  consists,  in  the  first  place,  of  the 
local  abstraction  of  blood  by  leeches  or  cupping  ;  the  leeches  being 
applied  at  the  orifice  or  behind  the  ear,  and  the  cupping  practised 
directly  below  it.  Leeches  may  also  be  applied  to  the  nostrils. 
Vapor  baths  should  frequently  be  applied  to  the  ear,  so  as  to  allow 
the  steam  to  penetrate  as  far  as  the  membrana  tympani.  The  throat 
should  be  repeatedly  gargled  with  hot  water.  The  patient  is  to  be 
kept  perfectly  quiet,  as  the  least  excitement  or  exercise  is  apt  to 
aggravate  the  symptoms  materially ;  the  room  should  also  be  dark- 
ened, and  every  sound  excluded  as  much  as  possible.  The  use  of 
mercury  will  be  found  very  efficacious,  especially  when  combined 
with  full  doses  of  opium  or  morphia.  When  the  pain  is  very  in- 
tense, it  is  desirable  to  keep  tlic  patient  for  several  hours  under  the 
influence  of  opium.  In  the  early  stages  of  the  affection  tartar  emetic 
proves  advantageous.  As  soon  as  the  discharge  appears,  the  meatus 
should  be  gently  syringed  with  a  copious  supply  of  warm  Avater 
thrice  daily. 

In  children  the  treatment  may  usually  be  less  active  ;  but  it  is 

17 


258  THE     DISEASES     OF     THE     EAR. 

important  to  try  the  application  of  leeches   and  counter-irritants, 
thoroughly  to  subdue  the  inflammation  as  rapidly  as  possible. 

Case  I.  Acute  inflammation  of  the  mucous  membrane  of  the  tym- 
panum ;  perforation  of  the  memhrana  tympani. — C.  C,  aged  40, 
sent  for  me  in  Kovember,  1852,  on  account  of  a  severe  attack  of 
pain  in  the  right  ear. 

History. — Two  days  previously  he  had  been  exposed  to  a  cold 
wind,  which  was  followed  towards  night  by  pain  in  the  ear.  During 
the  night  the  pain  became  much  aggravated,  and  seemed  not  only  to 
be  in  the  ear,  but  to  extend  over  the  whole  of  the  side  of  the  head, 
and  especially  over  the  region  of  the  mastoid  process.  There  was 
also  great  constitutional  disturbance,  confusion  in  the  head,  and  the 
most  extraordinary  noises.  "  At  the  same  moment,"  said  the  pa- 
tient, "I  seemed  to  be  standing  at  the  side  of  a  steam-engine,  snort- 
ing, puffing,  and  hissing,  and  yet  hearing  the  sound  of  a  church-bell 
tolling  at  a  distance." 

On  examining  the  ear,  the  membranous  meatus  was  observed  to 
be  red,  the  membrana  tympani  dull  and  opaque.  The  patient  was 
very  excitable  ;  pulse  quick ;  skin  hot.  Leeches  were  ordered  to 
be  applied  immediately  below  and  at  the  back  of  the  ear,  to  be  fol- 
lowed by  hot  fomentations  and  poultices.  Calomel  and  opium  were 
administered.  Under  this  treatment,  Avith  the  addition  of  a  blister 
to  the  nape  of  the  neck,  in  three  days  the  symptoms  gradually  sub- 
sided. At  the  end  of  the  third  day,  while,  the  head  was  on  the 
pillow,  a  feeling  as  of  something  bursting  in  the  ear  was  expe- 
rienced. This  was  followed  by  a  discharge  from  the  ear,  and  a  con- 
siderable additional  relief  to  the  pain.  On  further  examination,  a 
small  orifice  was  detected  in  the  lower  part  of  the  membrana  tym- 
pani, through  which  viscid  mucus  escaped  from  the  tympanum. 
There  was  also  great  dulness  of  hearing,  Avhich  was  the  more  dis- 
tressing to  the  patient  from  his  having  lost  the  use  of  the  other  ear 
during  childhood.  The  perforation  was  regarded  by  me  as  a  favor- 
able symptom,  being  likely  to  prevent  the  formation  of  membranous 
bands  in  the  tympanic  cavity.  The  inflammation  slowly  subsided  ; 
the  aperture  in  the  membrana  tympani  closed ;  and,  in  the  course  of 
ten  days,  the  patient  heard  as  well  as  before  the  attack.  His  hear- 
ing has  since  continued  good. 

In  some  cases  of  acute  inflammation  of  the  mucous  membrane  of 
the  tympanum,  the  pain  in  the  ear  is  not  so  violent  as  in  the  case 
just  detailed  ;  but  the  symptoms  of  cerebral  disturbance  are  more 


THE    CAVITY    OF    THE    TYMPANUM.  259 

distressing  and  continuous.  One  reason  for  the  cases  of  less  active 
inflammation  assuming  the  chronic  form,  seems  to  me  to  be,  that  a 
much  smaller  quantity  of  mucus  being  secreted,  the  membrana  tym- 
pani  does  not  give  way.  The  consequence  is,  the  mucus  collects  by 
degrees  in  the  tympanic  cavity,  and  thus  keeps  up  a  constant,  though 
slight,  irritation.  In  these  chronic  cases  the  symptoms  often  dis- 
appear after  a  discharge  from  the  ear  ;  and  careful  inspection  shows 
that  there  is  no  perforation  of  the  membrana  tympani,  and  that  the 
discharge  does  not  originate  from  the  tympanic  cavity,  but  has  its 
source  in  the  dermoid  meatus ;  being  the  result  simply  of  the  irrita- 
tion of  the  tympanic  mucous  membrane. 

The  following  case  will  illustrate  the  preceding  remarks. 

Case  II.  Acute  inflammation  of  the  mucous  membrane  of  the  tym- 
panum ;  prolonged  pain  in  the  head ;  discharge  from  the  meatus  ; 
relief. — M.  A.  K.,  aged  26,  was  admitted  under  my  care  in  St. 
Mary's  Hospital  on  October  6th,  1854. 

History. — About  a  month  ago  she  complained  of  pain  in  the  face 
and  soreness  of  the  throat,  together  with  pain  in  the  right  side  of 
the  head.  These  symptoms  were  followed  by  deafness  in  the  right 
ear.  At  the  time  of  admission  she  complained  of  pain  and  throb- 
bing in  the  right  ear,  extending  inwards  down  the  throat.  On  exa- 
mination, the  tongue  was  found  slightly  furred,  the  pulse  84  and 
small.  The  surface  of  the  meatus  was  red,  and  the  vessels  of  the 
dermoid  layer  of  the  membrana  tympani  were  distended.  The  crack 
of  the  nail  was  heard  when  made  close  to  the  ear.  Air  passed  into 
the  tympanic  cavity. 

Treatment. — Leeches  were  applied  below  the  ear ;  and  an  evapo- 
rating lotion  around  it. 

October  12th. — Pain  much  the  same.  To  repeat  the  leeches  and 
take  half  a  grain  of  the  chloride  of  mercury,  and  a  quarter  of  a 
grain  of  opium  every  night. 

October  16th. — Pain  somewhat  less,  but  still  severely  felt  deep  in 
the  ear. 

October  20th. — To  repeat  the  leeches. 

October  24th. — Much  better  ;  has  had  an  abundant  discharge 
from  the  ear,  followed  by  immediate  cessation  of  the  pain.  On  in- 
spection, it  was  seen  that  the  discharge  had  issued  from  the  surface 
of  the  meatus  ;  and  there  was  no  perforation  of  the  membrana 
tympani. 

October  28th. — The  pain  has  totally  disappeared. 


260  THE    DISEASES    OF    THE     EAR. 

1.  Acute  injlammation  affecting  the  portio  dura  nerve. — It  is  well 
known  that  the  portio  dura  nerve  passes  through  the  aqueduct  of 
Fallopius  along  the  upper  and  posterior  wall  of  the  tympanum  ;  but 

Fig.  84. 


The  Canal  for  the  Portio  Dura  Nerve  at  tlic  upper  part  of  the  tympanic  cavity  incomplete. 
A  dark  bristle  is  passed  through  the  canal. 

it  not  unfrequently  happens  that  the  inner  osseous  wall  of  this  canal 
is  incomplete,  and  thus  the  mucous  membrane  of  the  tympanum  is 
in  contact  with  the  outer  surface  of  the  nerve.  In  cases  of  acute 
inflammation  of  the  tympanic  mucous  membrane,  therefore,  the 
nerve  often  becomes  aflfected,  either  by  the  prolongation  of  the  in- 
flammation from  the  mucous  membrane  directly  to  the  nerve,  or 
through  the  wall  of  the  canal.  In  some  of  these  cases  the  mem- 
brana  tympani  ulcerates,  and  there  is  a  copious-  discharge  from  the 
tympanic  cavity ;  in  others  it  remains  intact. 

Case  III.  Acute  injiammation  of  the  mucous  memhrane  of  the 
tympanum ;  ulceration  of  the  memhrana  tympani;  iJaraJysis  of  the 
portio  dura  nerve  ;  cure. — E.  I.,  aged  23,  was  admitted  under  my 
care  at  the  St.  George's  and  St.  James's  Dispensary,  on  February 
28th,  1843. 

History. — He  stated  that  three  months  previously  he  was  suddenly 
seized  with  a  violent  attack  of  pain  in  the  right  ear,  which  extended 
over  the  side  of  the  head.  After  the  pain  had  lasted  for  about 
twenty-four  hours,  he  experienced  a  sensation  of  something  burst- 
ing in  the  ear,  followed  by  an  abundant  thick  and  offensive-smelling 
discharge.  During  the  attack  of  pain  he  had  much  giddiness,  lost 
the  use  of  the  right  side  of  the  face,  and  could  not  shut  his  right 
eye,  while  the  mouth  was  drawn  to  tlic  loft  side.  On  examination, 
an  orifice  was  observed  in  the  right  mcml)rana  tympani;  the  mucous 
membrane  of  the  tympanum  was  red  and  thick,  and  poured  out  a 
mucous  discharge.  He  was  ordered  to  apply  a  blister  behind  the 
car,  and  became  better,  having  no  return   of  the  pain   till   March 


THE    CAVITY    OF    THE    TY.MPANUM.  261 

lltli,  when  it  suddenly  reappeared  in  great  violence,  accompanied 
bj  a  singing  and  bj  sensations  of  pumping  and  throbbing  in  the 
ear.  These  symptoms  were  much  aggravated  by  coughing.  The 
discharge  was  abundant,  and  the  mucous  membrane  of  the  tym- 
panum very  red.  Leeches  -were  applied  below  the  ear,  which  was 
often  syringed  with  warm  water  ;  and  after  the  pain  was  somewhat 
subdued,  a  blister  was  applied  behind  the  ear.  Calomel  and  opium 
were  administered  until  the  gums  were  rendered  tender.  The  symp- 
toms gradually  subsided. 

April  11th. — Improved,  and  complains  of  but  little  pain. 

April  16th. — The  discharge  is  much  diminished  ;  the  orifice  in  the 
membrana  tympani  is  smaller ;  and  the  singing  noise  not  so  loud.  He 
cannot  yet  close  the  right  eye  or  use  the  mouth  freely,  but  the  power 
over  the  muscles  of  the  f^ice  is  certainly  greater.  Ordered  to  rub  the 
ointment  of  tartarized  antimony  behind  the  car.  From  this  time  the 
patient  gradually  improved,  and  on  the  3d  of  July  the  portio  dura 
nerre  had  regained  its  power,  and  the  quantity  of  discharge  had 
much  diminished. 

The  following  case  of  the  same  kind  occurred  in  a  younger  per- 
son : — 

Case  IV.  Acute  inflammation  of  the  mucous  membrane  of  the  right 
tympanum  ;  great  pain  in  the  head  ;  temporary  paralysis  of  the  right 
portio  dura  nerve. — Master  S.,  aged  5,  pale  and  weakly,  was  brought 
to  me  on  the  10th  of  February,  1850. 

History. — Three  months  previously,  the  right  ear  had  been  pulled 
rather  violently.  Fourteen  days  ago,  he  complained  of  pain  deep 
in  the  right  ear,  which  in  two  days  Avas  followed  by  discharge  and 
relief.  Lately  he  has  so  suffered  from  pain  on  the  riglit  side  of  the 
head,  that  he  constantly  presses  it  with  his  hand ;  and  for  a  week 
he  had  paralysis  of  the  right  side  of  the  face  :  but  perfectly  re- 
covered. To-day  he  again  complains  of  pain  in  the  ear.  On  exa- 
mination of  the  right  ear,  the  surface  of  the  meatus  was  observed  to 
be  red  and  swollen,  denuded  of  epidermis,  and  covered  by  a  thick 
white  discharge  ;  the  membrana  tympani,  which  was  in  the  same 
state,  bulged  outwards.  Leeches  below  the  ear,  the  use,  of  warm 
fomentations,  and  the  administration  of  tonic  medicines,  speedily 
reduced  the  pain  in  the  car  and  head,  and  he  was  sent  to  the  sea- 
side. On  March  7th,  about  a  month  after  I  had  first  seen  him,  I 
found  that  the  matter  had  made  its  way  through  a  small  orifice  in 
the  lower  part  of  the  membrana  tympani. 


262  THE     DISEASES     OF     THE     EAR. 

In  some  cases,  the  portio  dura  nerve  becomes  aifected  -wliile  the 
patient  is  under  treatment  for  secondary  syphilis.  Two  instances 
of  this  kind  have  occurred  to  me.  In  one,  the  patient  was  a  man  of 
twenty-three,  who  stated,  that  six  months  previous  to  his  consulting 
me,  he  had  complained  of  pain  in  his  left  ear  for  two  or  three  days, 
when  he  suddenly  lost  the  use  of  the  left  side  of  the  face,  and  found 
that  he  could  not  close  the  left  eye.  On  examination.,  the  left  mem- 
brana  tympani  was  rather  opaque,  although  its  surface  was  smooth. 
On  swallowing  with  closed  nostrils,  and  in  forcing  the  air,  it  passed 
freely  into  the  right  tympanic  cavity,  but  not  so  freely  into  the  left. 
The  patient  was  treated  with  small  doses  of  iodide  of  potassium,  and 
by  the  application  of  ointment  of  tartarized  antimony  behind  the 
ear.  After  six  weeks  of  this  treatment,  there  was  scarcely  any  trace 
of  the  paralysis  of  the  muscles  of  the  face,  and  the  hissing  sound  had 
greatly  diminished  ;  but  the  deafness  remained  as  before. 

2.  Acute  injlammation  extending  to  the  brain. — In  some  cases, 
the  inflamniiation  advances  from  the  tympanic  cavity  to  the  brain, 
and  death  is  the  consequence.  The  following  illustrative  case  is 
taken,  in  an  abridged  form,  from  Itard.' 

Case  V.  Acute  inflammation  of  the  mucous  membrane  of  the  tympa- 
num; inflammation  of  dura  mater  ;  death. — J.  B.,  aged  26,  of  a  san- 
guine temperament  and  robust  constitution,  was  received  into  the 
military  hospital  of  Val  de  Grace,  on  account  of  an  inflammation  of 
the  pleura.  On  the  fifth  day  of  the  attack,  he  was  seized  with  vio- 
lent pain  in  both  ears,  but  especially  in  the  left,  and  the  pain  was 
accompanied  by  a  rushing  noise  like  that  of  a  torrent.  On  the  sixth 
day  the  pain  increased  so  as  to  become  intolerable,  with  throbbing 
in  the  ears ;  pain  in  the  head  violent,  pulse  hard  and  full.  These 
symptoms  increased,  with  great  excitement,  delirium,  and  stupor, 
and  the  patient  died  on  the  seventh  day. 

On  dissection  of  the  right  oar,  the  mucous  membrane  of  the  tym- 
panum was  red,  swollen,  velvety,  and  covered  by  puriform  mucus,  of 
"which  the  cavity  was  full.  The  membrana  tympani  was  entire,  but 
its  inner  layer  very  thick  and  red.  The  mastoid  cells  were  full  of 
mucus.  In  the  left  ear,  where  the  pain  had  been  the  most  acute,  the 
mucous  membrane  of  the  tympanum  and  mastoid  cells  was  of  a  deep 
red  color,  but  there  was  no  secretion  of  mucus.  The  dura  mater 
covering  the  anterior  and  posterior  surfaces  of  the  petrous  bone  was 

'  Traite  des  Maladies  de  rOreille.     Vol.  i,  p.  193,  et  seq. 


THE    CAVITY    OF    THE    TYMPANUM.  263 

adherent  to  the  adjacent  cerebral  substance  ;  it  was  red  and  thick, 
and  separated  from  the  bone.  Between  the  bone  and  the  dura 
mater,  there  was  nearly  half  an  ounce  of  a  transparent  gelatinous 
fluid. 

A  case  somewhat  similar  to  the  foregoing,  I  liad  an  opportunity 
of  inspecting,  after  death,  with  Dr.  Blakely  Brown. 

Case  VI.  Acute  injlammation  of  the  tympanic  mucous  membrane 
after  whooping-cough;  dura  mater  inflamed:  effusion  of  serum  he- 
ttveen  it  and  the  jJetrous  bone,  and  in  the  lateral  ventricles. — The 
child  was  three  years  old,  and  shortly  before  the  fatal  seizure  had 
gone  through  an  attack  of  whooping-cough.  A  year  and  a  half  pre- 
vious to  her  death,  she  had  a  discharge  from  the  left  ear,  at  first  un- 
accompanied with  pain,  but  subsequently,  at  times,  she  suiFered  from 
acute  attacks  of  pain  in  the  ear  and  side  of  the  head,  previous  to,  and 
during  which,  the  discharge  subsided.  A  few  days  before  her  death, 
one  of  these  attacks  of  intense  pain  in  the  ear  and  head  came  on,  and 
resisted  every  remedial  measure  prescribed,  until  the  child  died  in 
the  greatest  sufferino;. 

On  inspection,  it  was  found  that  the  whole  of  the  membrana  tym- 
pani  had  been  destroyed,  with  the  exception  of  a  small  semilunar 
margin  at  the  upper  and  posterior  part.  The  mucous  membrane 
lining  the  tympanic  cavity  was  of  a  deep  red  color,  from  its  blood- 
vessels beincr  enlarged  and  distended  with  blood.  The  dura  mater 
was  much  congested  ;  serum  was  effused  between  it  and  the  petrous 
bone,  and  its  inner  surface  was  adherent  to  the  arachnoid.  Serum 
was  also  effused  beneath  the  arachnoid,  and  in  the  lateral  ventricles. 

In  cases  of  typhus  fever,  I  have  found  the  dura  mater  partaking 
of  the  inflammation  of  the  tympanic  mucous  membrane.  One  case 
of  this  kind  was  that  of  a  girl,  aged  IG,  who  died  of  typhus  fever, 
after  seven  weeks'  illness.  She  was,  to  a  certain  degree,  dull  of 
hearing  from  the  commencement  of  the  attack,  but  not  previously. 

Dissection.  Right  ear. — The  meatus  externus  contained  a  large 
quantity  of  thick  matter,  and  the  dermis  and  periosteum  were  so 
soft  as  to  be  easily  detached  from  the  bone.  The  membrana  tym- 
pani  had  been  removed  by  ulceration.  The  tympanic  mucous  mem- 
brane was  thick  and  soft,  and,  although  the  ossicles  were  in  their 
natural  position,  the  long  process  of  the  malleus  had  been  absorbed. 
The  cavity  contained  thick  mucus  ;  and  the  dura  mater  was  detached 
from  the  upper  part  of  the  tympanum. 

Left  ear. — The  meatus  was  full  of  pus ;  its  lining  membrane  was 


264  THE     DISEASES     OF     THE     EAR. 

soft,  and  a  small  strip  only  of  the  membrana  tympani  remained. 
The  tympanum  and  mastoid  cells  were  full  of  thick  muco-purulent 
matter ;  the  lining  membrane  being  thick,  soft,  and  disconnected 
from  the  bone.  The  dura  mater  adhered  so  slightly  to  the  upper 
■wall  of  the  tympanum,  that  it  was  disengaged  by  the  gentlest  trac- 
tion. 

In  other  cases  of  death  from  typlius  fever,  I  found  the  dura  mater 
inflamed,  and  separated  from  the  upper  surface  of  the  petrous  bone 
by  serum.  In  one  case,  that  of  a  patient  aged  17,  during  the  attack 
of  fever,  but  not  previous  to  it,  there  was  great  dulness  of  hearing 
for  nine  days,  and  discharge  from  the  left  ear  four  or  five  days  prior 
to  death.  On  dissection,  the  dura  mater  was  found  to  partake  of 
the  inflammation  of  the  mucous  membrane ;  the  bone  was  also  very 
vascular,  and  it  was  separated  from  the  dura  mater  by  a  small  quan- 
tity of  serum. 

The  presence  of  scrofulous  matter  in  the  tympanic  cavity  some- 
times gives  origin  to  the  most  formidable  cerebral  symptoms,  and, 
in  some  cases,  without  leaving  any  traces  of  inflammation  of  the 
brain  after  death.  In  the  following  case,  which  occurred  under  the 
care  of  Dr.  Chambers,  in  St.  Mary's  Hospital,  and  Mliich  I  had  the 
opportunity  of  seeing  during  life,  I  think  there  is  no  doubt  but  that 
the  cerebral  symptoms  arose  from  the  afiection  of  the  ear. 

Case  VII.  Accumulation  of  scrofulous  matter  in  the  tympanum; 
acute  inflammation  of  the  mucous  membrane  ;  severe  cerebral  symp- 
toms; death. — S.  B.,  aged  10,  was  admitted  into  St.  Mary's  Hos- 
pital on  the  21st  April,  1854,  with  the  following  history : — A'^omit- 
ing,  heat  of  skin,  headache ;  occasional  shrill  screaming  had  com- 
menced on  the  18th,  and  continued  to  the  time  of  admission.  The 
bowels  had  not  acted  since  the  19th.  She  had  formerly  a  discharge 
from  the  right  ear  ;  but  that  had  latterly  ceased,  though  deafness 
remained. 

On  examination,  the  pulse  was  rapid  and  regular  ;  the  skin  hot 
and  dry  ;  the  face  flushed ;  the  eyes  heavy  but  shiny  ;  the  pupils 
naturally  afi'ected  by  light.  There  was  a  tendency  to  a  sort  of  coma- 
tose sleep,  but  she  was  easily  roused  by  speaking  to  her. 

April  21st. — Ten  leeches  to  be  applied  to  the  head  ;  also  ice ; 
one  and  a  half  grain  of  calomel  every  hour,  and  a  purgative  in  the 
morning. 

22d. — Urine  albuminous,  probably  from  the  calomel.  No  more 
vomiting.     Bowels  opened  several  times.     Complains  of  pain  in  the 


THE    CAVITY    OF    THE    TYMPANUM.  265 

cardiac  region.  Keeps  boring  her  head  into  the  pillow,  and  occa- 
sionally screaming.  No  pain  in  the  head.  Tongue  white  and  furred  ; 
pulse  108,  regular  ;  one  of  the  evacuations  was  mucous  and  bloody, 
the  rest  dark.  Ordered  the  calomel  every  three  hours,  and  a  blister 
to  the  nape  of  the  neck. 

23d. — The  same  symptoms  exaggerated,  with  violent  delirium 
occasionally  and  screaming,  alternating  with  a  half-comatose  state. 
This  continued  till  her  death,  at  two  in  the  morning  of  the  25th, 
the  face  and  lips  remaining  flushed  till  the  time  of  decease. 

Post-mortem  Inspection. — The  tympanic  cavity  contained  scrofu- 
lous matter.  The  mucous  membrane  lining  the  tympanic  cavity 
was  very  red,  and  its  bloodvessels  very  distended.  The  Avhole  of 
the  petrous  bone  and  the  dura  mater  covering  it,  was  also  of  a  deep 
red  color,  from  the  distention  of  the  vessels. 


[c.)    CHRONIC    INFLAMMATION   AND  HYPERTROPHY  OF    THE    TYMPANIC 
MUCOUS    MEMBRANE. 

I  am  not  sure  that  the  above  designation  is  perfectly  correct, 
because  it  appears  probable  that  hypertrophy  of  the  mucous  mem- 
brane sometimes  takes  place  without  the  occurrence  of  any  appre- 
ciable inflammatory  symptoms  ;  indeed,  in  children  having  a  ten- 
dency to  glandular  enlargements,  the  mucous  membrane  appears  to 
become  thickened  without  the  slightest  sign  of  inflammation.  In 
some  cases,  however,  chronic  inflammation  undoubtedly  precedes 
the  hypertrophy. 

Pathological  Observations. — The  mucous  membrane  lining  the 
tympanic  cavity  frequently  undergoes  the  process  of  hypertrophy. 
This  delicately  thin  mucous  membrane,  so  fine  in  its  natural  state 
as  often  to  require  the  aid  of  touch  as  well  as  sight  to  determine  its 
presence,  may  nevertheless  become  so  thickened  as  to  fill  the  whole, 
or  nearly  the  Avhole  of  the  tympanic  cavity.  From  being  like  a 
piece  of  the  finest  silver  paper,  it  becomes  more  like  velvet.  Instead 
of  throwing  out  just  so  much  mucus  as  suitices  to  lubricate  the  sur- 
face of  the  membrane,  it  pours  forth  a  thick  and  viscid  secretion 
which  often  fills  up  the  entire  cavity  unoccupied  by  the  hypertro- 
phied  lining.  In  some  cases  where  the  Eustachian  tube  is  partially 
or  wholly  closed  by  the  hypertrophied  membrane,  the  mucus  presses 
upon  the  inner  surface  of  the  membrana  tympani ;  gradually  by  its 


266  THE     DISEASES     OF     THE     EAR. 

pressure  causing  absorption,  and  ultimately  produces  an  orifice 
through  which  the  mucus  escapes  into  the  meatus,  giving  rise  to 
what  Avas  formerly  called  a  case  of  otorrhoea.  This  discharge 
througli  an  orifice  in  the  membrana  tympani,  in  the  "way  just  de- 
scribed, is  one  of  the  common  results  of  scarlet  fever  ;  and  though 
it  does  not  appear  probable  that  the  mucous  membrane  should 
become  hypertrophicd  in  so  short  a  space  of  time  as  that  in  Avhich  a 
case  of  scarlet  fever  is  developed,  yet  it  is  still  possible  that  it  may 
be  so.  My  belief,  however,  is,  that  in  these  cases  of  catarrh  of  the 
mucous  membrane,  hypertrophy  has  usually  preceded  the  attack  of 
fever  ;  and  that  this  condition  of  the  tympanum  and  other  organs 
are  evidence  of  a  -weakened  state  of  the  system.  Sometimes  this 
condition  of  chronic  inflammation  of  the  mucous  membrane  extends 
upwards  through  the  osseous  Avail,  and  affects  the  dura  mater.  The 
constant  attacks  of  earache  in  some  children  are  due  to  this  afi"ec- 
tion. 

The  predispositu/  cause  is  the  most  essential  point  to  ascertain  in 
respect  to  this  affection,  since  it  almost  invariably  occurs  in  those 
whose  vital  power  has  been  lowered  by  disease,  or  some  other  debili- 
tating influence.  Improper  food  or  clothing,  insufficient  ventilation 
or  exercise,  or  some  analogous  cause,  may  almost  ahvays  be  detected ; 
and  when  detected,  should  be  at  once  removed,  if  possible,  or  at  least 
diminished  by  the  skill  of  the  surgeon  ;  after  which,  the  next  step  is 
to  assist  in  remedying  the  effects.  It  will  usually  be  observed,  on 
general  examination,  that  the  child  is  pale,  flabby,  deficient  in  bodily 
strength  and  spirit,  Avith  the  submaxillary,  or  cervical  glands,  often 
hypertrophicd,  and  tlie  heart  weak.  On  inspecting  the  ear,  the 
dermis  of  the  meatus  is  commonly  thicker  than  natural,  so  that  the 
calibre  of  the  meatus  is  diminished,  and  there  is  some  difficulty  in 
obtaining  a  distinct  vicAv  of  the  membrana  tympani  ;  but  when  the 
latter  organ,  or  a  portion  of  it,  is  seen,  its  surface  is  found  to  be 
less  shiny  than  natural,  and  not  unfrequently  of  a  AAhitish  color, 
resembling  the  appearance  of  parchment  more  or  less  sodden. 
Sometimes,  Avhile  the  long  process  of  the  malleus  is  unseen,  the 
processus  brevis  stands  out  prominently.  When  the  Eustachian 
tube  is  also  obstructed,  the  membrana  tympani  is  externally  much 
more  concave  than  natural.  On  exploring  tlie  tympanic  caA'ity  by  the 
otoscope,  air  is  not  unfrequently  heard  most  distinctly  to  enter  the 
cavity,  although  the  sounds  developed  by  its  entrance  are  abnormal. 
Instead  of  the  normal  crackling,  a  flap,  as  of  air  suddenly  bloAA-n 


THE    CAVITY    OF    THE    TYMPANUM.  267 

into  a  wet  bladder,  is  heard.  At  times,  during  the  act  of  swallow- 
ing with  closed  nostrils,  the  air  does  not  enter  the  tympanum,  and 
a  forcible  expiration  with  closed  nostrils  is  requisite  to  insure  its 
admission ;  but  when  the  air  is  forced  in,  a  sound  similar  to  the  last 
described  is  produced,  but  of  a  louder  and  more  defined  character. 
In  certain  cases  there  is  an  accumulation  of  mucus  in  the  tympanic 
cavity,  so  that  when  air  is  forcibly  injected  a  gurgling  or  bubbling 
sound  is  heard. 

Treatment. — As  before  stated,  the  first  step  is  to  discover  what  has 
been  done  or  is  doing  in  violation  of  nature's  laws,  and  to  insist,  as  far 
as  possible,  on  a  proper  mode  of  living.  This  having  been  attended 
to,  remedial  medical  measures  may  be  hopefully  applied.  These  are, 
gentle  counter-irritation  over  the  mastoid  processes  by  means  of  vesi- 
cating plaster  or  solution  ;  and,  where  there  is  much  congestion,  with 
frequent  attacks  of  pain,  a  leech  or  two  may  be  applied  beneath  each 
ear  ;  a  stimulating  gargle  may  be  prescribed,  and  cold  Avater  freely 
used  outside  the  throat.  The  tonsils,  often  much  enlarged,  may 
be  washed  with  a  solution  of  nitrate  of  silver  (twenty  grains  to  an 
ounce),  and  tonics  administered.  In  very  advanced  cases,  where 
the  health  is  much  deranged,  the  child  amcmic,  and  its  physical 
powers  greatly  depressed,  it  may  be  requisite  at  once  to  insist  upon 
sea  air,  or  at  least  change  of  air.  The  prognosis  in  these  cases  is 
usually  favorable ;  by  careful  management,  the  mucous  membrane  is 
gradually  restored  to  a  more  natural  state  ;  the  mucus  disappears 
from  the  tympanic  cavity,  and  the  patient  regains  his  hearing  in  a 
month  or  two.  Cases  of  a  less  favorable  character  occasionally 
occur,  where  the  earache  has  been  violent,  the  inflammation  acute, 
and  rigid  bands  of  adhesion  have  formed  in  the  tympanic  cavity,  or 
the  membranes  of  the  articulations  of  the  ossicles  have  become  rigid : 
these,  of  course,  demand  longer  perseverance  and  greater  attention, 
but  are  usually  eventually  cured. 


[d.)   CHRONIC   CATARRHAL   INFLAMMATION    OF   THE    MUCOUS   MEM- 
BRANE  LININCf   THE   TYMPANIC    CAVITY. 

This  affection  differs  from  the  last  in  the  circumstance  that  mucus 
has  collected  in  so  large  a  quantity  as  to  distend  the  tympanic 
cavity,  and  press  upon  the  inner  surface  of  the  membrana  tympani, 
so  that  this  structure,  becoming  gradually  atrophied  and  yielding  to 


268  THE    DISEASES     OF    THE    EAR. 

the  pressure  of  the  mucus  "within,  has  given  way,  and  the  discharge 
issues  through  the  orifice  thus  made. 

The  treatment  of  this  cLass  of  cases  diflfers  from  that  of  the  pre- 
ceding in  the  use  of  the  syringe  and  warm  water  twice,  or  oftener, 
daily,  to  effect  a  complete  removal  of  the  secretion.  The  great 
desire  of  the  friends  to  stop  the  discharge  must  be  earnestly  con- 
tended against,  since  that  discharge  is  simply  an  effect  and  not  a 
cause  ;  and  it  is  the  latter  which  requires  to  be  removed.  Among 
the  causes  to  Avhich  attention  is  frequently  called,  is  the  admission  of 
cold  air  to  the  delicate  mucous  membrane  of  the  tympanum  through 
the  external  meatus.  In  these  cases,  the  artificial  membrana  tym- 
pani  is  to  be  used  where  the  age  of  the  child  will  permit  it,  and  re- 
ference must  be  made  to  the  chapter  where  it  is  described,  together 
with  its  mode  of  application. 


ie.)    CHRONIC  CATARRHAL    INFLAMMATION  OP  THE    TYMPANIC   MUCOUS 
MEMBRANE   AFFECTING   THE    BONE,    DURA    MATER,    OR    BRAIN. 

The  first  effect  upon  the  tympanic  mucous  membrane  produced  by 
scarlet  fever  and  other  predisposing  diseases,  is  usually  a  simple  ca- 
tarrhal inflammation,  i.  e.,  the  ciliated  mucous  membrane,  which  is 
naturally  extremely  thin,  and  pours  out  a  very  small  quantity  of 
thin  mucus,  becomes  hypertrophied,  and  secretes  copiously  a  viscid 
matter,  which,  being  too  abundant  and  thick  to  escape  through  the 
natural  excretory  passage, — the  Eustachian  tube, — gradually  fills  the 
tympanic  cavity,  and  presses  against  the  inner  surface  of  the  mem- 
brana tympani,  causing  the  partial  or  entire  destruction  of  that 
organ  ;  the  mucus  then  freely  escapes  into  the  meatus,  and  forms 
one  of  the  class  of  cases  usually  comprised  under  the  term  otorrlioea, 
it  being  in  reality  a  case  of  simple  catarrh  of  the  mucous  membrane 
of  the  t^niipanura.  So  long  as  there  is  a  free  exit  for  the  discharge, 
I  believe  that  the  disease  rarely  extends  to  the  cerebrum  ;  and  for- 
tunately, in  a  large  proportion  of  cases  where  the  ear  is  injured  by 
scarlet  fever  or  other  diseases,  so  large  a  section  of  the  membrana 
tympani  is  removed,  that  the  viscid  mucus  secreted  has  free  egress 
from  the  tympanum.  But,  as  stated,  the  membrana  tympani  some- 
times remains  entire,  or  has  only  a  small  aperture,  or  a  part  falls  in- 
wards and  becomes  attached  to  the  promontory,  thus  making  a  sep- 
tum, shutting  off  the  tympanic  cavity  from  the  meatus.     Sometimes 


THE     CAVITY    OF    THE    TYMPANUM.  269 

membranous  bands  stretch  across  the  tympanum,  or  scrofulous  de- 
posits accumulate.  Bj  one  or  other  of  the  above  circumstances,  the 
secretion  of  the  tympanic  mucous  membrane  is  prevented  passing  out- 
wards ;  and  it  gradually  distends  the  tympanic  cavity  till  it  affects 
the  osseous  ^valls  ;  and  tlius  disease  of  the  membranes  of  the  brain, 
or  of  the  brain  itself,  is  originated. 

Although,  as  just  stated,  simple  chronic  catarrh  of  the  tympanic 
mucous  membrane,  when  there  is  free  egress  for  the  discharge,  rarely 
extends  to  the  brain,  the  dura  mater  may,  nevertheless,  become 
diseased.  In  chronic  catarrhal  inflammation  the  tympanic  mucous 
membrane  becomes  much  hypertroj^hied  and  its  vessels  enlarged; 
and  as  these  vessels  are,  through  the  medium  of  the  bone,  directly 
continuous  Avith  those  of  the  dura  mater,  it  is  not  surprising  that  the 
latter  membrane  should  be  affected,  and  we  find  it  accordingly  un- 
dergoing slight  changes.  One  of  these  is  hypertrophy;  another  is 
detachment  from  the  petrous  bone;  and  the  third  is  atrophy  and 
extremely  firm  adhesion  to  the  bone.  The  bone  is  also  liable  to  be 
slightly  affected. 

The  following  case  illustrates  the  effects  of  simple  catarrh  of  the 
tympanic  mucous  membrane,  with  free  egress  for  the  secretion. 

Case  I.  Catarrh  of  the  tympanic  mucous  membrane  ;  hone  soft. — 
A  woman  who  had  been  deaf  in  both  ears  during  many  years,  died 
of  apoplexy,  at  the  age  of  64.  On  dissection  of  the  right  ear,  nearly 
the  whole  of  the  membrana  tympani  was  found  to  have  been  de- 
stroyed ;  the  small  portion  which  remains  is  thick  and  soft,  and  is 
in  contact  with  the  promontory.  The  malleus  has  disappeared,  but 
the  incus  remains,  and  is  attached  to  the  stapes ;  the  latter  bone 
being  Avholly  concealed  by  the  thick  mucous  membrane.  The  upper 
osseous  wall  is  soft. 

Chronic  catarrhal  inflammation  of  the  mucous  membrane  of  the 
tympanum,  2vhere  the  memhrana  tympani  is  entire,  and  where  there 
has  been  but  sliglit  catarrh  from  the  mucous  membrane,  may  also 
produce  disease  in  the  dura  mater ;  but  so  far  as  my  experience 
extends,  no  cases  have  occurred  in  which  the  disease  has  advanced 
to  the  injury  of  the  brain,  so  long  as  there  is  not  more  discharge 
than  can  pass  away  through  the  Eustachian  tube.  Cases  of  this  class 
have  come  before  me  when  making  dissections  of  the  ears  of  patients 
who  have  died  of  other  diseases ;  and  the  following  brief  notices 
indicate  the  state  of  incipient  disease  that  may  be  present ;  and 
farther  consideration  will  show  that   it  is  likely  to  assume  a  very 


270  THE     DISEASES     OF    THE     EAR. 

serious  character,  when,  under  the  influence  of  exciting  causes,  the 
quantity  of  the  secretion  is  much  increased. 

Dissection.  Mucous  memhrane  of  the  tympanum  thick ;  memhrana 
tympani  entire  ;  hone  carious  ;  dura  mater  ulcerated  ;  the  arachnoid 
in  contact  ivith  the  tympanic  mucous  memhrane. — A  man  Avho  had 
been  many  years  deaf,  died  of  consumption  at  the  age  of  50. 
Right  Uar. — The  memhrana  tympani  is  Avhite,  concave,  and  very 
thick,  and  the  whole  of  its  inner  surface  adheres  to  the  inner  "wall  of 
the  tympanum,  "while  the  ossicula  are  firmly  hound  together  by  hands. 
The  membrane  lining  the  mastoid  cells  is  thick,  and  the  cells  contain 
a  viscid  fluid.  I/cft  ear. — In  much  the  same  state  as  the  right,  but 
there  was  a  carious  orifice  in  the  upper  wall  of  the  tympanum.  The 
dura  mater  was  thin  in  some  parts,  and  ulcerated  in  others,  so  that 
the  outer  surface  of  the  visceral  arachnoid  was  in  contact  with  the 
mucous  membrane  of  the  tymjianum. 

Dissection.  3Iucou8  memhrane  of  the  tympanum  thick  ;  memhrana 
tympani  entire;  hone  carious;  dura  mater  atrophied,  uJeerated. — 
A  woman,  aged  Qb,  died  of  paralysis.  Many  years  previous  to  her 
death,  deafness  slowly  came  on  in  the  right  ear,  after  repeated  at- 
tacks of  earache.  Dissection  of  right  ear. — Memhrana  tympani 
white  and  thick,  and  a  large  membranous  band  connects  the  incus 
with  the  inner  wall  of  the  tympanum,  so  as  nearly  to  conceal  the 
stapes.  The  tympanic  mucous  membrane  is  four  or  five  times  its 
natural  thickness,  and  adheres  firmly  to  the  bone.  The  upper  os- 
seous wall  of  the  tympanum  is  cribriform,  so  that  at  various  points 
the  thickened  mucous  membrane  is  in  contact  with  the  outer  surface 
of  the  dura  mater.  The  dura  mater  is  very  thin,  and  presents  two 
or  three  small  orifices. 

In  another  woman,  aged  70,  who  died  of  apoplexy,  and  who  had 
been  many  years  deaf,  the  following  was  the  condition  of  the  left 
ear.  The  memhrana  tympani  was  thick  and  opaque,  more  especially 
at  its  posterior  part ;  and  its  inner  surface  firmly  adhered  to  the 
inner  wall  of  the  tympanum  and  to  the  stapes,  Avhich  bone  is  con- 
cealed by  bands  of  adhesion.  The  upper  osseous  wall  of  the  tympa- 
num is  carious,  and  presents  several  large  orifices,  which  allow  the 
dura  mater  to  be  in  contact  with  the  thickened  mucous  membrane. 

Treatment. — Chronic  catarrhal  inflammation  of  the  mucous  mem- 
brane lining  the  tympanum  is  usually  attended  by  so  extensive  a 
destruction  of  the  memhrana  tympani,  that  fortunately  the  discharge 
finds  a  free  outlet,  however  viscid  it  may  be.     The  cfi"ects,  therefore, 


THE    CAVITY    OF    THE    TYMPANUM.  271 

are  confined  to  a  certain  amount  of  congestion  of  the  dura  mater 
covering  the  petrous  bone.  In  cases  of  this  simple  kind,  it  is  there- 
fore not  uncommon  to  meet  Avith  symptoms  of  slight  cerebral  irrita- 
tion, -which  gradually  yield  to  treatment  by  local  depletion  and 
gentle  counter-irritation.  The  majority  of  these  cases  result  from 
an  attack  of  scarlet  fever.     The  following  is  an  instance  : — 

Case  II.  Catarrh  from  the  tympanic  mucous  membrane  after 
scarlet  fever;  destruction  of  eacli  memhrana  tymiKini ;  attacks  of 
giddiness. — Miss  A.  H.,  aged  15,  consulted  me  in  November,  1845, 
on  account  of  a  discharge  from  each  ear,  accompanied  by  dulness  of 
hearing  and  frec^uent  giddiness.  She  stated  that  seven  years  pre- 
viously she  had  an  attack  of  scarlet  fever,  for  -which  she  -was  con- 
fined to  her  bed.  During  the  fever  a  copious  discharge  issued  from 
each  ear,  and  the  hearing  Avas  greatly  diminished.  For  the  last 
three  years  there  has  been  so  much  less  discharge,  that  it  has  not 
reached  the  orifice  of  the  car  for  two  or  three  weeks  at  a  time ;  but 
with  this  diminution  of  the  discharge  the  deafness  has  been  aggra- 
vated.    She  now  complains  of  frequent  attacks  of  giddiness. 

Upon  examination,  each  membrana  tympani  was  discovered  to  be 
entirely  absent,  and  the  mucous  membrane,  which  was  thick  and 
red,  was  the  source  of  the  secretion.  Watch  heard  at  one  inch  from 
the  right  ear,  and  at  two  inches  from  the  left.  The  treatment  con- 
sisted in  the  application  of  leeches  below  the  ears ;  the  use  of  a 
very  weak  solution  of  the  diacetate  of  lead  as  an  injection  after 
tepid  water ;  and  the  administration  of  the  twentieth  of  a  grain  of 
the  bichloride  of  mercury  twice  daily.  Under  this  treatment  the 
congestion  of  the  mucous  membrane  of  the  tympanum  greatly 
diminished,  the  discharge  gradually  decreased  in  quantity,  and  the 
giddiness  disappeared. 

Other  cases  might  be  cited  in  which  catarrhal  inflammation  of 
the  tympanic  mucous  membrane  had  been  accompanied  by  symptoms 
of  giddiness ;  some  resulted,  as  in  the  last  case,  from  scarlet  fever ; 
others  from  measles.  The  treatment  in  each  case  was  very  similar; 
and  although  in  some  instances  the  pain  extended  over  a  great  part 
of  the  head,  and  "was  even  accompanied  at  times  by  vomiting,  all 
ultimately  recovered. 

In  the  case  above  cited  the  entire  membrana  tympani  was  absent, 
so  that  the  whole  of  the  discharge  could  be  removed  by  syringing. 
In  those  which  follow,  part  only  of  the  membrana  tympani  was 
destroyed,  and  the  remainder  prevented  the  egress  of  the  matter ; 


272  THE    DISEASES     OF    THE     EAR. 

additional  care  had  therefore  to  be  exercised  to  insure  the  complete 
removal  of  the  dischai'ge. 

Case  III.  Catarrh  from  the  mucous  membrane  of  the  left  tym- 
panum;  perforation  of  the  memhrana  tympani ;  pain  in  the  left  side 
of  the  head. — F.  11.,  an  architect,  aged  44,  consulted  me  in  1852, 
respecting  a  discharge  from  the  left  ear,  accompanied  by  pain  and 
tenderness  over  the  left  side  of  the  head.  He  stated  that  since 
childhood  he  had  been  subject  to  a  discharge  from  the  left  ear, 
which  had  never  ceased  for  more  than  a  few  days.  During  the  last 
five  or  six  years  he  has  also  complained  of  pain  in  the  loft  side  of 
the  head,  extending  in  front  as  far  as  the  temple,  and  behind  over 
the  region  of  the  mastoid  process.  Slight  excitement  or  fatigue 
produces  considerable  aggravation  of  the  symptoms.  At  times, 
the  pain  in  the  ear  comes  on  suddenly,  and  is  followed  by  very 
abundant  secretion.  About  a  month  ago,  during  a  cold,  he  had  an 
attack  of  pain  in  the  ear,  attended  by  a  loud  whizzing  sound  and 
great  additional  tenderness  over  the  left  side  of  the  head.  On 
exa77iinatio7i,  an  ulcerated  orifice,  about  two  lines  in  diameter,  was 
observed  in  the  posterior  part  of  the  left  membrana  tympani, 
through  which  oozed  a  large  quantity  of  thick  tenacious  discharge, 
havino;  an  offensive  odor.  On  removing;  this,  the  mucous  membrane 
of  the  tympanmn  was  seen  to  be  red  and  much  thicker  than  natural, 
so  as  to  project  towards  the  orifice  in  tlie  membrana  tympani,  and 
in  some  degree  prevent  the  free  passage  of  the  secretion  through 
the  orifice.  The  treatment  in  this  case  consisted  in  keeping  up  a 
discharge  from  the  mastoid  process,  and  in  administering  small 
doses  of  the  bichloride  of  mercury  in  conjunction  with  sarsaparilla. 
The  ear  was  also  syringed  twice  daily  with  warm  Avater,  care  being 
taken  that  the  stream  was  directed  to  the  orifice  in  the  membrana 
tympani,  so  that  the  water  might  be  made  to  enter  the  tympanic 
cavity,  and,  by  mixing  with  the  mucous  secretion,  so  soften  it  as  to 
facilitate  its  discharge  through  the  orifice  of  the  membrane.  This 
treatment  was  very  successful,  for  the  pain  around  the  car  dimin- 
ished greatly  by  degrees,  and  the  attacks  of  pain  within  the  ear 
became  less  frequent.  The  quantity  of  the  discharge,  however, 
remained  much  the  same  until  a  weak  solution  of  the  diacetate  of 
lead  was  injected.  This  treatment  was  pursued  for  four  months, 
at  the  end  of  which  time  the  patient  no  longer  complained  of  any 
pain  in  the  ear  or  head,  and  the  quantity  of  discharge  had  greatly 
decreased. 


I 


THE    CAVITY    OF     THE     TYMPANUM.  273 

Cases  similar  to  the  above  being  frequently  met  with  in  practice, 
the  following  brief  particulars  of  a  very  similar  instance  are  sub- 
joined. 

Case  IV.  Catarrlial  injiiwimation  of  the  tympanic  mucous  mem- 
hrane  ;  perforation  of  the  memhrana  tyrnpani;  pain  in  the  head,  and 
giddiness ;  irritation  of  the  portio  dura  nerve. — Miss  M.  S.,  aged 
30,  says,  that  since  childhood,  with  exception  of  an  interval  of  two 
years'  duration,  she  has  had  a  discharge  from  the  right  ear,  follow- 
ing an  eruption  on  the  head.  For  eight  or  nine  years  has  com- 
plained of  pain  at  the  top  of  the  head,  with  heat  and  a  sense  of 
weight.  This  pain  sometimes  suddenly  shoots  across  the  head  from 
the  right  ear.  She  suffers  at  times  from  giddiness,  and  for  the  last 
fcAV  months  has  had  a  feeling  of  confusion  in  the  head  ;  six  months 
ago  had  twitchings  of  the  muscles  on  the  right  side  of  the  face.  On 
examination,  the  memhrana  tympani  of  the  right  ear  was  seen  to  be 
perforated  at  its  upper  and  anterior  part,  the  aperture  measuring 
about  a  line  and  a  half  in  diameter.  Mucus  oozed  through  the 
aperture,  and  having  been  removed,  the  mucous  membrane  of  the 
tympanum  was  observed  to  be^  thick  and  red.  The  treatment  was 
the  same  as  in  the  last  case,  except  that  leeches  were  applied  below 
the  ears  once  a  week.  After  three  months  all  the  symptoms  were 
much  diminished,  and  the  patient  was  ordered  to  continue  the  counter- 
irritation  and  the  injection  with  warm  water. 

From  the  situation  of  the  orifice  in  the  memhrana  tympani  in  the 
above  case,  it  will  be  observed  that  in  tlie  usual  position  of  the  head 
during  the  day,  a  portion  of  the  mucus  must  have  been  confined  to 
that  part  of  the  tympanic  cavity  which  Avas  beneath  the  orifice  ; 
there  was,  however,  a  free  escape  of  the  mucus  during  the  recum- 
bent position,  as  there  was  then  an  opportunity  for  the  complete 
evacuation  of  the  contents  of  the  tympanic  cavity ;  and  as  the  symp- 
toms were  not  very  urgent,  it  appeared  advisable  to  try  the  effect  of 
counter-irritation,  instead  of  enlarging  the  orifice  in  the  memhrana 
tympani. 

In  treating  the  class  of  cases  now  under  consideration,  it  is  of 
great  importance  to  be  able  to  decide  when  the  memhrana  tympani 
should  be  perforated  by  artificial  means,  or  when  an  orifice  in  it 
should  he  enlarged.  To  the  perforation  of  the  memhrana  tympani, 
much  objection  exists  on  account  of  the  difficulty  of  keeping  the 
aperture  open.  It  is  seldom  that  a  punctured  aperture,  even  of 
large  size,  docs  not  close  in  the  course  of  two  or  three  days.     I  have 


274  THE     DISEASES     OF     THE     EAR. 

found,  even  after  making  a  triangular  flap  and  turning  it  down,  that 
the  orifice  thus  produced  sometimes  closed  in  a  few  days  by  the 
effusion  of  fibrine.  It  is,  however,  not  always  possible  to  make  a 
triangular  aperture  of  this  kind,  either  on  account  of  the  small 
calibre  of  the  meatus,  or  the  extreme  sensibility  of  the  surface  of 
the  membrana  tympani.  The  only  sure  wa}^  of  keeping  open  an 
aperture  in  this  membrana  with  which  I  am  acquainted,  consists  in 
applying  to  it  the  point  of  a  fine  stick  of  potassa  cum  calce.  Such 
a  proceeding  appears,  at  first  sight,  to  be  attended  with  danger  to 
the  adjacent  parts ;  but,  in  reality,  the  action  of  this  substance  is 
wholly  under  coiitrol ;  for  the  injection  of  warm  Avater  at  once 
entirely  stops  its  escharotic  properties.  During  and  after  the  appli- 
cation of  this  remedy,  to  which  I  have  resorted  in  the  destruction 
of  polypoid  groAvths,  I  have  never  known  any  inflammation  to  arise. 
At  the  same  time  there  is  no  doubt,  that  in  cases  such  as  Ave  are 
noAV  considering,  Avhen  there  are  symptoms  of  cerebral  irritation, 
extreme  caution  should  be  used,  and  every  other  possible  measure 
adopted  before  having  recourse  to  this,  or  indeed  any  other  opera- 
tive proceeding  ;  and  as  remedial  measures  of  a  different  kind  are 
generally  sufficient  to  alleviate  or  cure  the  disease,  the  operation  of 
perforating  the  membrane  is  rarely  required.  The  potassa  cum 
calce  has  been  used  by  me  in  only  one  case. 

In  those  cases  of  catarrhal  inflammation  where  the  quantity  of 
discharge  from  the  tympanic  mucous  membrane  has  not  been  suffi- 
cient to  cause  ulceration  of  the  membrana  tympani,  but  Avhere  the 
superabundant  quantity  has  passed  away  through  the  Eustachian 
tube,  it  seems  to  me  that,  as  a  general  rule,  unless  the  disease  has 
made  great  progress  and  threatens  the  life  of  the  patient,  the  ordi- 
nary remedial  measures  already  adverted  to  Avill  be  found  sufficient 
to  arrest  its  progress  and  produce  considerable  iraproA'ement.  The 
folloAving  cases  will  illustrate  this  branch  of  the  subject,  and  it  Avill 
be  seen  that  they  differ  from  those  last  quoted  in  the  circumstance 
of  the  membrana  tympani  being  still  entire. 

Case  V.  Chronic  injlammation  of  the  mucous  membrane  of  the 
tympanum,  without  j^eff oration  of  the  membrana  tympani;  giddi- 
ness, ^c. — M.  C,  aged  27,  consulted  me  on  the  15th  of  February, 
1857.  She  said  that  for  four  months  she  has  had  at  times  a  sensa- 
tion of  pricking  in  the  right  ear,  accompanied  by  a  humming  noise, 
deafness,  giddiness,  a  sensation  of  swimming  in  the  head,  and  pain 
over  the  right  side.     During  the  last  fcAV  days  has  complained  of  a 


THE    CAVITY    OF    THE    TYMPANUM.  275 

throbbing  in  the  ear,  attended  with  great  pain,  and  followed  by  dis- 
charge:  has  also  been  "light-headed"  at  night.  Every  time  she 
draws  in  breath  through  the  nose,  she  states  there  is  a  rattling  sound 
in  the  ear,  and  for  a  minute  or  two  she  hears  better.  The  hearing 
is  also  better  after  a  copious  discharge.  On  inspection^  the  surface 
of  the  meatus  was  found  to  be  red,  denuded  of  epidermis,  and  secret- 
ing a  muco-purulent  fluid.  The  membrana  tympani  was  opaque,  es- 
pecially at  its  lower  part ;  the  Eustachian  tube  pervious,  and  the 
poAver  of  hearing  much  diminished.  Considering  tiie  case  to  be  one 
of  chronic  inflammation  of  the  mucous  membrane  of  the  tympanum, 
Avith  a  collection  of  mucus  in  the  lower  part  of  the  tympanic  cavity, 
and  that  the  irritation  of  the  meatus  was  only  a  symptom  of  this  in- 
flammation, the  treatment  adopted  consisted  in  the  application  of 
leeches  below  the  ear,  and  of  blisters  behind  it ;  under  this  treat- 
ment the  head-symptoms  greatly  diminished,  while  the  hearing  was 
much  improved.  On  the  12th  of  May,  the  patient  was  again  seized 
with  violent  pain  in  the  right  ear,  extending  across  the  head  and 
towards  the  forehead.  On  the  17th  she  became  much  worse,  and 
was  insensible  for  some  hours.  Blisters  were  applied  to  the  nape  of 
the  neck,  and  a  constant  discharge  was  kept  up  through  them  for 
some  weeks ;  small  doses  of  calomel  were  also  administered  until  the 
gums  became  tender.  The  acute  symptoms  were  soon  abated,  but 
counter-irritation  was  kept  up  for  a  long  period,  and  iodide  of  potas- 
sium and  sarsaparilla  were  afterwards  administered.  Treated  in 
this  way  the  symptoms  of  cerebral  irritation  wholly  subsided,  and 
the  power  of  hearing  greatly  improved. 

Although  it  is  difficult  to  determine  positively  whether  there  is  a 
collection  of  mucus  in  the  tympanic  cavity,  the  history  and  symp- 
toms of  the  case,  and  the  peculiar  sodden  condition  of  the  mem- 
brana tympani,  such  as  was  presented  in  this  case,  especially  at  the 
lower  part,  left  little  doubt  in  my  mind  that  mucus  had  collected ; 
and  the  second  attack  was  probably  the  result  of  a  collection  of  this 
fluid,  causing  irritation  and  pressure  on  the  labyrinth.  It  is  pos- 
sible that  more  speedy  relief  might  have  been  effected,  by  allowing 
an  escape  of  the  mucus  through  an  orifice  in  the  membrana  tym- 
pani ;  but  I  was  quite  aware,  from  previous  operations,  of  the  great 
difficulty  of  keeping  open  the  aperture,  even  if  the  means  employed 
did  not  cause  a  serious  increase  of  the  inflammation.  The  impor- 
tant rule  to  bear  in   mind,   is  to  keep  up  counter-irritation  long 


276  THE     DISEASES     OF     THE     EAR. 

enough  to  cause  absorption  of  the  fluid,  and  the  arrest  of  the  inflam- 
mator}^  action  Avhich  produces  the  secretion. 

As  stated,  there  is  some  diflSculty  in  ascertaining  positively  whe- 
ther there  is  a  collection  of  mucus  in  the  tympanic  cavity.  Some- 
times the  opacity  and  sodden  appearance  of  the  membrana  tympani 
is  the  chief  indication ;  but  often  the  gurgling  sound,  produced  by 
the  entrance  of  air  into  the  tympanum,  or  the  peculiar  flap,  result- 
ing from  the  air  striking  against  a  soft  flaccid  membrane,  shows,  at 
least,  that  there  is  a  considerable  quantity  of  mucus  in  the  cavity. 
The  following  case  will  further  elucidate  the  subject  : — 

Case  yi.  Chronic  catarrh  of  the  mucous  mcmhrane  of  the  tym- 
panum ;  giddiness,  and  symptoms  of  cerebral  invitation. — E.  Mid- 
dleton,  aged  14,  Avas  admitted  under  my  care,  at  the  St.  George's 
and  St.  James's  Dispensary,  in  December,  1849.  She  had  an  at- 
tack of  measles  at  four  years  of  age  ;  since  which  she  has  com- 
plained of  much  pain  in  both  ears  and  in  the  front  of  the  head,  at- 
tended by  throbbing  and  frequent  attacks  of  giddiness,  especially 
when  walking  quickly.  At  tjmes,  also,  she  has  been  delirious  and  very 
violent.  The  head-symptoms  have  much  increased  in  severity  since 
the  cessation  of  the  discharge,  which  took  place  nine  months  pre- 
vious to  her  consulting  me. 

On  examination,  the  membrana  tympani  of  the  right  ear  was  seen 
to  be  very  white,  and  parts  of  it  had  fallen  in.  Hearing  distance, 
with  watch,  half  an  inch.  Left  ear. — The  membrana  tympani  is 
milky  white  :  hearing  distance  same  as  right  ear.  Air  passes  into 
each  tympanum  during  an  expiration  with  closed  nostrils,  producing 
a  gurgling  sound.  The  treatment  consisted  in  the  use  of  a  blister- 
ing ointment  to  the  nape  of  the  neck,  by  Avliich  a  constant  discharge 
Avas  kept  up  for  more  than  a  month,  and  in  giA'ing  tonic  medicines. 
By  sloAv  degrees  the  head-symptoms  abated ;  she  avus  free  from 
giddiness  for  days,  and  the  occasional  attacks  Avere  in  a  mitigated 
form,  and  for  short  intervals  only.  At  the  end  of  tAvo  months,  she 
had  so  far  improved,  as  to  be  able  to  enter  service  as  a  housemaid. 

Althoujzh  the  n;ci^tiral  cause  of  this  kind  of  inflammation  is  most 
usually  an  attack  of  scarlet  fever,  measles,  or  common  cold,  this 
affection  may  folloAV  a  bloAv  on  the  ear  or  head ;  and  it  is  probable 
that  in  the  folloAving  case  a  bloAV  was  the  })rimary  cause  of  the 
disease. 

J.  S.,  aged  35,  Avas  admitted  under  my  care,  in  the  Hospital,  on 
May  1st.  1853,  complaining  of  pain  in  the  riglit  ear  and  doAvn  the 


THE    CAVITY    OF    THE    TYMPANUM.  277 

back,  accompanied  by  faintncss  when  the  nose  Avas  blown,  or  the  ear 
was  pressed.  She  stated  that  when  she  was  ten  years  old,  she 
received  a  blow  on  the  right  car,  since  which  that  car  has  been  deaf. 
Tavo  years  ago,  discharge  took  place  from  the  right  ear,  and  has 
continued.  On  examination,  the  menibrana  tympani  was  observed 
to  have  fiillen  in,  and  there  was  a  valvular  opening  at  the  lower  part, 
through  which  discharge  was  forced  upon  blowing  the  nose.  Regard- 
ing the  case  as  one  of  long  standing  disease  of  the  tympanic  mucous 
membrane,  causing  irritation  of  the  brain,  I  at  once  ordered  a  seton 
to  be  placed  in  the  back  of  the  neck,  the  effect  of  Avhich  was  slowly, 
but  entirely,  to  remove  pain  from  the  ears,  the  head,  and  the  spine. 

The  general  opinion  respecting  the  mode  in  which  disease  pro- 
gresses from  the  ear  to  the  brain,  appears  to  be  that  the  bone 
becomes  carious,  the  dura  mater  ulcerates,  the  arachnoid  and  the 
pia  mater,  and  ultimately  the  substance  of  the  brain,  participate  in 
the  disease,  as  the  result  of  direct  extension  from  the  ear.  A  care- 
ful examination  of  the  post-mortem  appearances  found  in  some  of 
the  fsital  cases,  shows  that  the  disease  does  not  always  advance  from 
the  ear  to  the  brain  as  the  result  of  continuity ;  indeed,  in  some 
instances,  an  abscess  is  developed  in  the  brain  without  ulceration  of 
the  mucous  membrane  of  the  tympanum,  or  caries  of  the  bone.  It 
would  appear  that  constant  irritation  in  the  tympanic  cavity,  pro- 
duced by  chronic  inflammation  of  the  mucous  membrane,  with  the 
absence  of  a  free  outlet  for  the  matter,  is  sufficient  to  produce 
an  abscess  in  the  substance  of  the  cerebrum.  Dr.  Abercrombie 
states :  There  is  reason  to  believe  that  extensive  suppuration  within 
the  cavity  of  the  tympanum  is  capable  of  producing  symptoms  of 
great  urgency,  especially  if  there  should  be  any  difficulty  of  finding 
"an  outlet;"  but  the  evidence  derived  from  dissection  shows  that 
these  symptoms  of  great  urgency  are  associated  with  disease  of  the 
cerebral  substance,  without  the  existence  of  caries  of  the  petrous 
bone.  Thus  in  a  case  published  by  Dr.  Joseph  Williams,*  of  which 
the  following  is  an  abstract,  there  was  no  caries  of  the  petrous  bone. 

Case  VII.  Ulceration  of  the  tympanic  mucous  membrane  ;  abscess 
in  the  substance  of  the  brain  ;  petrous  bone  not  carious. — E.  B., 
aged  23,  not  strong,  but  her  health,  till  about  a  fortnight  before  her 
death,  had  been  uniformly  good :  she  was  then  suddenly  seized  with 
violent  headache,  and  most  severe  pain  in  the  right  ear  ;  chilliness 

*  Treatise  on  the  Ear.     London,  1840. 


278  THE    DISEASES    OF    THE    EAR. 

next  came  on,  -svliicli  in  a  short  time  amounted  to  actual  rigors.  The 
pain  in  the  ear  now  increased,  and  for  several  hours  there  was  an 
oozing  of  blood  from  the  meatus.  The  next  day  the  discharge  be- 
came thin  and  ichorous ;  the  febrile  symptoms  rapidly  increased ; 
she  fell  into  a  state  of  semi-stupor,  and  the  discharge  became  thick, 
fetid,  and  purulent.  She  died  on  the  third  day  after  the  appearance 
of  the  acute  symptoms. 

Autopsy. — The  dura  mater  was  softened,  and  easily  broken  down 
over  the  petrous  bone.  In  the  substance  of  the  middle  cerebral 
lobe  was  an  abscess  containing  an  ounce  of  pus,  which  had  a  fetid 
odor,  was  of  a  dark  yellow  appearance,  and  was  mixed  with  serum. 
The  abscess  itself  appeared  to  be  about  the  size  of  a  five-shilling 
piece.  It  had  penetrated  deeply  into  the  substance  of  the  brain, 
and  its  contents  were  mixed  with  blood.  The  portion  of  the  brain 
surrounding  the  abscess  was  soft  and  very  vascular.  The  surface 
of  the  petrous  bone  was  of  a  somewhat  dark  color,  and  on  sawing 
into  it,  the  inner  portion  of  the  petrous  bone  Avas  found  increased  in 
vascularity,  and  even  in  some  parts  ulcerated ;  the  secretion  was 
fetid  and  puriform,  and  the  mucous  membrane  completely  destroyed. 
The  niembrana  tympani  was  ulcerated  nearly  through,  and  some  of 
the  bones  of  the  external  ear  were  destroyed.  Dr.  Williams  adds : 
"  Dr.  Alison  has  communicated  to  me  a  case  where  abscess  was 
found  in  the  brain,  consequent  upon  disease  attended  with  discharge. 
The  petrous  bone  was  sound,  consequently  there  was  no  communica- 
tion between  the  matter  of  the  ear  and  that  of  the  brain." 

In  other  cases,  a  considerable  portion  of  healthy  brain  is  found 
to  exist  between  the  abscess  and  the  petrous  bone.  For  the  particu- 
lars of  the  following  case,  and  for  the  opportunity  of  making  the  dis- 
section, I  am  indebted  to  Dr.  Merriman. 

Case  VIII.  Catarrh  of  the  mucous  membrane  of  the  tympanum, 
since  measles;  attack  of  arachnitis;  death;  petrous  hone  not  cai-ious ; 
abscess  in  the  substance  of  the  brain;  adjacent  cerebral  matter  healthy. 
— M.  K.,  a  widow,  aged  26,  of  a  scrofulous  diathesis,  and  much  con- 
fined to  the  house  as  a  maker  of  military  caps,  came  under  the  care 
of  Dr.  Merriman,  at  the  Westminster  General  Dispensary,  for  a 
cough,  on  the  7th  January,  1846.  On  the  26th,  she  complained  of 
earache  on  the  right  side,  and  then  said  that  she  had  been  subject 
to  a  discharge  from  the  right  ear  since  an  attack  of  measles  when  a 
child :  the  discharge  was  at  times  very  offensive.  Previous  to  the 
present   attack,  no  pain  had  ever  been  felt ;  but  she  is  said,  for 


THE    CAVITY     OF    THE    TYMPANUM. 


279 


twelve  or  sixteen   months  to  have  suffered  much  from  headaches, 
being  at  times  forgetful  and  very  giddy.     She  has  also  fallen  a.vay 
very  much.     At  first,  only  fomentations  were  ordered,  which  were 
followed  by  leeches;  but  without  any  benefit.     The  pani  greatly 
increased,  and   was    described  as  if,  at  times,  a  knife  were  being 
thrust  into  the  ear ;  and  then,  as  if  there  was  a  sawing  outside  the 
ear  at  its  ed<re.     During   paroxysms  of  pain  the  patient   screamed 
out  suddenly"  and  then  could  not  open  her  mouth.     On  two  occa- 
sions a  small  quantity  of  discharge  was  observed,  but  its  appearance 
afforded  no  relief.    When  the  pain  at  all  relaxed  she  lay  m  a  partial 
sleep      On  the  17th  of  February  she  became  insensible,  but  put  out 
her  tongue  when   loudly  told  to  do  so,  and  then   relapsed   into  a 
comatose  state.     She  died  on  the  evening  of  the  17th,  twenty-three 
days  after  the  attack  of  pain  had  commenced. 

Autops>/.—^Yhen  the  skull  was  sawn' through,  pus  flowed  trom 
within  the  dura  mater;  and  upon  examination  it  was  found  to  come 
from  an  abscess  which  occupied  the  whole  of  the  upper  part  of  the 
riaht  cerebral  hemisphere.     The  substance  of  the  surrounding  brain 
was  healthy.     The  dura  mater  above  the  part  cut  off  by  the  saw 
presented  a  patch  of  coagulable  lymph,  about  the   size  of  a  four- 
penny  piece;  lymph  was  also    effused  on  the  surface  of  the  dura 
mater,  covering  the  petrous  bone,  and  a  portion  of  it  was  detached 
from  the  bone.     Upon  dissection  of  the  ear,  the  membrana  tympani 
was    absent;    the    tympanic    mucous   membrane,  and    that    of   the 
mastoid  cells,  was  thick  and  soft,  and  covered  by  a  large  quantity 
of  caseous,  scrofulous  matter.     The  upper  tympanic  wall  was  of  a 
dark    color,  extremely  thin,  and   perforated   by  numerous   blood- 
ve^^sels.     The  dura  mater   covering  the  upper  part  of  the  petrous 
bone    an<l    that    lining    the    squamous   bone,  was    very  thick    and 
detached  from  the  bone,  and  a  large  quantity  of  purulent  matter 
was  deposited  between   the   dura  mater  and   the   arachfioid.      Ihe 
arachnoid   membrane    was    highly   congested.     In   some    parts   the 
purulent  matter  had  passed    through  the  dura  mater,   and  was  in 
contact   with   the   bone.     The    outer    surface  of   the  dura   mater, 
forming  the  lateral  sinus,  was  rough  where  in  contact  with  the  in- 
flamed bone;  and  the  internal  surface  of  the  sinus  had  portions  of 

fibrin  adhering  to  it. 

The  presence  of  a  portion  of  healthy  brain  between  the  abscess 
and  the  petrous  bone,  has  induced  some  observers  to  conclude  that 
abscess  in  the  cerebrum  is  the  primary  disease,  and  affection  of  the 


280  THE     DISEASES     OF    THE    EAR. 

ear  the  result.  The  objections  to  this  opinion  are :  Firstly,  that 
the  cases  of  abscess- in  the  cerebrum  are  usually  preceded  by  a  long 
standing  affection  of  the  ear.  Secondly,  that  the  portion  of  bone 
which  becomes  carious  is  far  from  being  the  most  dependent  part 
of  the  cerebral  fossa.  And,  thirdly,  that  although  the  abscess  may 
be  very  large,  the  walls  of  the  tympanum  only  are  the  real  seat  of 
disease  in  the  bone. 

The  very  insidious  progress  of  the  disease  in  its  course  towards 
the  brain  has  been  already  adverted  to.  In  some  cases  no  symp- 
tom indicates  to  the  patient  that  the  brain  has  become  affected  until 
the  sudden  appearance  of  the  acute  stage ;  the  presence  of  a  dis- 
charge from  the  ear  and  a  certain  amount  of  deafness  are,  as  they 
assure  the  medical  man,  the  only  unpleasant  symptoms.  Never- 
theless, it  does  seem  to  me  that,  by  a  careful  professional  exa- 
mination of  the  patient,  the  early  stages  of  the  disease  might  be 
detected ;  for  in  cases  where  my  suspicions  have  been  aroused  by 
the  condition  of  the  ear  and  the  inward  progress  of  the  disease,  I 
have  not  unfrequently  found  an  unnatural  sensibility  of  the  brain 
upon  percussing  the  suspected  side  of  the  head.  In  some  cases  the 
discharge  may  take  place  for  a  month  or  two,  and  then  disappear 
for  a  similar  period ;  Avliere  this  cessation  occurs,  however,  there  is 
usually  tenderness  in  or  about  the  ear.  The  simple  fact  of  discharge 
occasionally  issuing  from  the  ear  should  induce  the  medical  man  to 
make  a  careful  investigation. 

The  exciting  causes  of  the  acute  cerebral  symptoms  are  various  : 
a  blow  upon  the  head,  violent  exercise,  a  cold,  stimulating  applica- 
tions, or  any  dppressing  influence,  may  bring  them  on.  Sometimes 
no  exciting  cause  can  be  detected  beyond  the  progress  of  the  chronic 
affection  of  the  ear. 

One  of  the  first  symptoms  of  the  disease  assuming  an  acute  form 
is  the  cessation  of  the  discharge  ;  this  is  the  result  of  inflammatory 
action,  and  it  is  so  commonly  associated  with  the  origin  of  acute 
symptoms,  that  the  stoppage  of  the  discharge  has  been  considered 
as  the  cause  instead  of  the  effect  of  acute  inflammation  ;  and  medi- 
cal men  have  been  afraid  to  stop  a  discharge  from  the  ear,  lest  in- 
flammation of  the  brain  should  be  induced.  If  this  fear  were  confined 
to  the  exclusion  of  all  irritating  astringents  in  these  cases,  it  would 
be  salutary  ;  but  when  it  gives  rise  to  a  belief  that  it  is  injudicious 
to  interfere  in  any  way  with  a  disease  of  the  ear  which  is  slowly 
progressing,  and  which,  if  neglected,  would  probably  terminate  in 


THE    CAVITY    OF    THE    TYMPANUM.  281 

the  deatli  of  the  patient,  it  may  act  very  prejudicially.  Mr.  Wilde, 
in  his  work  on  "  Aural  Surgery,"  before  alluded  to,  has  some  inte- 
resting observations  on  this  subject. 

Two  cases  of  abscess  in  the  substance  of  the  cerebrum,  arising 
from  catarrhal  inflammation  of  the  mucous  membrane  of  the  tym- 
panum, have  been  already  described.  In  that  which  follows,  the 
^lost-mortcm  examination  was  attended  by  me  with  the  late  Mr. 
Farish.  Death  took  place  from  arachnitis,  and  an  abscess  was  found 
in  the  middle  cerebral  lobe ;  but  the  cause  of  the  irritation  appeared 
to  be  the  presence  of  scrofulous  matter  in  the  tympanum. 

Case  IX.  Scrofulous  matter  in  the  tympanic  cavity ;  caries  of  the 
upper  ivall  of  the  tympanum ;  arachnitis;  abscess  in  the  middle 
cerebral  lobe. — Miss  H.  G.,  aged  9i,  fair  and  delicate,  but  not  un- 
healthy, had  measles  when  quite  a  child,  though  not  severely ;  since 
the  measles,  has  had  an  offensive  discharge  from  the  left  ear,  at- 
tended by  occasional  attacks  of  pain.  On  tlic  5th  May,  1845,  she 
was  seized  with  symptoms  of  active  fever.  She  did  not  complain  of 
headache,  but  Avhen  questioned,  said  there  Avas  some  uneasiness 
about  the  vertex.  The  discharge  had  ceased.  There  was  constant 
vomiting.  Calomel  and  opening  medicines  were  administered,  fol- 
lowed by  effervescent  salines.  On  the  7th,  she  seemed  well ;  every 
unpleasant  symptom  had  vanished ;  her  pulse  was  natural,  her 
tongue  clean,  food  was  relished,  and  there  was  no  pain.  On  the  8th, 
the  bad  symptoms  reappeared.  On  the  10th,  she  complained  of  pain 
in  the  left  ear,  which,  by  degrees,  became  excruciating  to  the  last 
degree  ;  she,  however,  retained  her  faculties  till  from  tAvelve  to  twenty 
hours  previous  to  her  death.  The  only  symptoms  of  derangement 
of  the  nervous  system  were,  some  vomiting  and  a  slight  degree  of 
paralysis  of  the  muscles  on  the  left  side  of  the  face.  The  remedial 
means  em])loyed  Avere  leeches,  calomel,  James's  powder,  and  a  little 
opium  ;  and  these  were  employed  freely  from  the  11th.  In  spite 
of  all  efforts,  she  gradually  became  comatose ;  but  even  then  fre- 
quently shrieked  out  from  pain  on  the  left  side  of  the  head.  She 
died  at  midnight,  on  the  15th,  tAvelve  days  after  the  occurrence  of 
the  first  symptoms. 

Autopsy. — Upon  removing  the  calvaria,  the  dura  mater  was 
observed  to  be  red,  and  its  bloodvessels  distended.  The  cavity  of 
the  arachnoid  on  the  left  side  contained  nearly  half  an  ounce  of 
yellow  purulent  matter;  lymph  was  deposited  upon  the  inferior  sur- 
face of  the  posterior  lobe  of  the  left  hemisphere.     The  arachnoid 


282  THE     DISEASES     OF     THE     EAR. 

and  pia  mater  covering  the  inferior  surface  of  the  middle  lobe  on 
the  left  side,  Avere  thick  and  dark  colored  over  a  superficies  about 
the  size  of  a  sixpence.  This  thickened  portion  corresponded  Avith 
an  orifice  in  the  dura  mater  covering  the  upper  surface  of  the 
petrous  bone.  In  the  interior  of  the  left  middle  cerebral  lobe, 
there  "svas  an  abscess  as  large  as  a  small  hen's  egg,  in  which  a 
quantity  of  dark-colored  fetid  matter,  of  a  watery  consistence,  was 
contained.  There  was  no  communication  between  the  abscess  and 
the  cavity  of  the  arachnoid.  The  dura  mater  covering  the  upper 
surface  of  the  petrous  bone  Avas  three  or  four  times  its  usual  thick- 
ness, and  its  inner  surfiice  darker  colored  than  natural  and  rough  ; 
being  in  some  parts  firmly  adherent  to  the  bone,  and  in  others 
detached  from  it.  About  the  centre  of  the  upper  surface  of  the 
petrous  bone,  the  dura  mater  presented  an  orifice  about  a  line  in 
diameter,  directly  beneath  which  was  another  and  smaller  one  in 
the  petrous  bone,  measuring  about  a  quarter  of  a  line  in  diameter. 
The  latter  orifice,  and  several  smaller  ones  about  the  size  of  pin- 
holes, were  filled  by  concrete  scrofulous  matter,  which  projected 
from  the  tympanic  cavity.  The  superior  Avail  of  the  cerebellar 
corner  of  the  tympanum  presented  two  carious  orifices.  The  tym- 
panic cavity  and  mastoid  cells  Avere  completely  full  of  scrofulous 
matter,  having  the  consistence  of  soft  cheese,  by  which  the  mastoid 
cells  appeared  to  be  much  dilated  ;  the  mucous  membrane  of  the 
tympanum  Avas  but  slightly  thicker  than  natural,  and,  where  orifices 
existed,  they  appeared  to  have  been  produced  by  atrophy,  resulting 
from  the  pressure  of  the  scrofulous  matter  rather  than  from  the  pro- 
cess of  ulceration.  The  greater  part  of  the  substance  of  the  mem- 
brana  tympani  had  been  destroyed,  and  the  remaining  fibres  Avere 
adherent  to  the  inner  Avail  of  the  tympanum. 


(/.)     ULCERATION    OF    THE    MUCOUS    MEMBRANE    OF   THE    TYMPANUM. 

This  disease  is  rarely  met  Avith,  and  its  treatment  is  the  same  as 
that  of  chronic  catarrhal  inflammation. 

The  folloAving  case,  belonging  to  this  class,  AA^as  supplied  to  me  by 
Mr.  Obre,  together  Avith  the  preparation. 

Case  I.  Scrofulous  ulceration  of  the  tympanic  mucous  membrane; 
destruction  of  the  upper  wall  of  tympanum  ;  purulent  degeneration 
of  the  middle  cerebral  lobe. — A  young  lady,  aged  18,  of  scrofulous 


THE    CAVITY    OF    THE    TYMPANUM. 


283 


diathesis,  imd  avIio  was  treated  by  a  medical  friend,  was  attacked, 
on  November  20th,  184G,  witli  fever  and  hysterical  symptoms,  un- 
accompanied by  any  pain.  The  following  day  symptoms  of  pleuritis 
appeared,  accompanied  by  severe  pain  in  the  right  side  of  the  head. 
It  was  noAv  ascertained  that  she  had  been  deaf  in  the  right  ear  for 
two  years,  and  that  tlie  deafness  was  preceded  by  a  fetid  discharge. 
Notwithstanding  the  most  active  treatment,  the  symptoms  of  cere- 
bral irritation  grew  worse  daily,  and  death  occurred  on  the  ninth 
day  of  the  attack.  The  patient's  memory  and  intellect  were  perfect 
up  to  the  hour  of  her  death,  which  was  preceded  by  epileptic  fits. 
There  was  a  very  fetid  odor  about  the  ear,  but  no  discharge.  On 
dissection,  the  periosteum  was  found  detached  from  the  exterior, 
and  the  dura  mater  from  the  interior,  of  the  squamous  bone,  and 
separated  by  dark-colored  pus.  The  dura  mater  on  the  right  side 
of  the  head  was  gangrenous  over  a  large  surface  ;  and  the  middle 

Fig.  85. 


The  internal  surface  of  the  Temporal  Bone,  showing  the  Tympanic  Cavitj'  in  a  state  of 
disease  ;  the  entire  upper  osseous  wall  of  the  Tympanum  having  been  destroyed  by 
caries. 


lobe  of  the  right  hemisphere  was  in  a  state  of  suppuration,  being 
principally  composed  of  pus.  On  careful  inspection  of  tlie  petrous 
bone,  the  whole  of  the  upper  wall  of  the  tympanum  was  found  to 
have  been  destroyed  by  caries  ;  and  the  tympanic  cavity  communi- 


284  THE     DISEASES     OF     THE     EAR. 

cated  "with  that  of  the  cerebrum  by  an  aperture,  measuring  three- 
quarters  of  an  inch  in  length,  and  a  third  of  an  inch  in  breadth. 

It  thus  appears  that  in  some  cases  the  disease  of  the  ear,  instead 
of  an  abscess,  produces  2^ftrii(e7it  degeneration  of  the  substance  of  the 
brain. 

Case  11,  Ulceration  of  the  mucous  membrane  of  the  tympanum; 
caries  of  the  bone;  partial  destruction  of  the  portio  dura  nerve,  and 
softening  of  the  dura  mater. — John  Cochrane,  a  laborer,  aged  44, 
■was  admitted  nnder  the  care  of  Dr.  Kingston,  at  the  Westminster 
Hospital,  for  consumption,  in  October,  1849.  His  history  is,  that 
twenty-four  years  previously,  discharge  took  place  from  the  right 
ear,  and  has  continued  ever  since.  He  has  long  been  deaf  in  that 
ear,  but  has  not  complained  of  any  head-symptoms.  On  examining 
the  ear  the  membrana  tympani  "was  absent,  and  the  tympanic  mucous 
membrane  was  covered  by  an  opaque  discharge  like  cream.  When 
that  was  removed,  the  mucous  membrane  Avas  seen  to  be  thick  and 
its  surface  rugose.  The  patient  died  of  consumption  about  a  month 
after  his  admission  into  the  hospital.  Some  days  previous  to  his 
death,  there  was  a  paralytic  condition  of  the  muscles  of  the  right 
side  of  the  face  ;  but  there  was  a  partial  recovery  of  their  action  a 
short  time  previous  to  death.  On  dissection,  the  mucous  membrane 
lining  the  tympanic  cavity  was  found  very  thick  and  dark  colored, 
excepting  at  the  anterior  part,  where  it  had  been  destroyed  by  ulce- 
ration. The  stapes  was  absent.  At  the  upper  part  of  the  tympanum 
the  bone  was  carious  ;  the  aqueduct  of  Fallopius  was  exposed  for  a 
space  of  more  than  a  line  and  a  quarter  in  length,  and  the  portio 
dura  nerve,  in  a  soft  and  ulcerated  state,  protruded  from  it.  The 
part  of  the  nerve  towards  the  tympanum  was  gelatiniform  in  its 
consistence,  and  extended  downwards  so  as  to  cover  the  fenestra 
ovalis.  The  posterior  half  of  the  nerve  was  healthy.  The  dura 
mater  covering  the  petrous  bone  was  thicker  than  natural ;  and  a 
small  circular  portion,  about  a  line  and  a  quarter  in  diameter,  was 
of  a  dark  brown  color,  and  of  a  pulpy  consistence.  It  was  slightly 
raised  above  the  surface  of  the  surrounding  membrane,  and  on  being 
touched  broke  up,  and  exposed  a  carious  orifice  in  the  bone  below 
it.  The  bone  around  tlie  orifice  was  ver}'  thin.  The  brain  Avas  not 
diseased. 

In  this  case  there  appeared  no  obstacle  to  the  free  escape  of  the 
discharge,  excepting  its  tenacity  and  its  concretion  in  the  tympanic 
cavity  ;  and  it  is  worthy  of  observation  in  a  practical  point  of  vicAV, 


THE     CAVITY     OF     THE     TYMPANUM.  285 

that  unless  the  syringe  ^vith  warm  water  be  frequently  used,  the 
matter  secreted  by  the  mucous  membrane  of  the  tympanum  is  apt 
to  accumulate  and  solidify,  and  so  cause  a  certain  degree  of  irrita- 
tion in  the  adjacent  parts. 

In  the  following,  which  is  the  last  case  I  shall  cite  in  reference  to 
this  class  of  diseases  of  the  tympanum,  the  disease  was  evidently  of 
a  scrofulous  character.  The  mucous  membrane  of  the  tympanum 
had  ulcerated,  and  its  place  was  occupied  by  scrofulous  matter. 
The  substance  of  the  brain  had  also  undergone  scrofulous  degenera- 
tion. 

Case  III.  Ulceration  of  the  mucous  memhrane  of  the  left  tympa- 
num ;  softening  and  tubercular  deposit  in  the  corresponding  cerebral 
lobe. — AVni.  K.,  aged  4,  was  admitted  under  my  care,  at  the  St. 
George's  and  St.  James's  Dispensary,  in  March,  1849.  He  was  de- 
scribed as  never  having  had  good  health,  his  bowels  having  always 
been  irregular,  and  his  abdomen  tumid.  In  earliest  infancy  dis- 
charge of  offensive  matter  took  place  from  the  left  ear,  and  has 
never  disappeared  for  more  than  a  few  days  at  a  time.  The  ear 
appeared  tender  to  the  touch,  although  no  pain  had  been  complained 
of.  _  Has  suffered  from  pain  in  the  forehead  and  eyes  for  some 
months. 

Three  days  before  my  seeing  him,  he  fell  down  at  school  in  what 
appeared  to  be  a  fit,  and  remained  insensible  for  some  minutes. 
Upon  his  recovery  he  was  found  to  have  lost  the  use  of  the  muscles 
on  the  right  side  of  the  fi\ce  and  body.  "When  seen  by  me  he  Avas 
in  a  state  of  extreme  exhaustion,  speechless  and  hemiplegic.  On 
the  following  day  he  complained  of  great  pain  in  the  left  ear  and 
the  left  side  of  the  head,  anil  there  Avas  an  abundant,  creamy,  offen- 
sive discharge  from  the  ear. 

On  examination,  the  Avhole  of  the  membrana  tympani  Avas  found 
to  have  been  destroyed,  the  tympanic  mucous  membrane  had  disap- 
peared, and  the  cavity  contained  thick,  caseous,  scrofulous  matter. 
The  pain  in  the  head  and  the  convulsive  fits  increased  in  intensity  ; 
he  often  remained  insensible  for  hours  together  ;  his  strength  gra- 
dually declined  ;  and,  in  spite  of  tlie  most  active  treatment  Avith 
leeches  and  mercury,  he  died  on  the  21st  of  May. 

Autopsif,  sixteen  hours  after  death. — The  dura  mater  covering  the 
upper  surface  of  the  cerebral  hemispheres  Avas  healthy  ;  but  In  the 
substance  of  the  left  cerebral  hemisphere,  above  the  middle  cerebral 
lobe,  was  a  space  measuring  three  inches  from  behind  forwards,  an 


286  THE     DISEASES     OF    THE    EAR. 

inch  and  a  half  from  without  inwards,  and  an  inch  from  above  down- 
wards, which  was  much  harder  than  natural,  and  studded  with  tuber- 
cles ;  and  between  this  mass  and  the  lateral  ventricle  the  brain  was 
pulpy.  In  the  left  lateral  ventricles  was  a  small  quantity  of  turbid 
serum.  The  dura  mater  covering  the  upper  surface  of  the  petrous 
bone  Avas  more  vascular  than  natural,  and  on  its  free  surface  was  a 
patch  of  blood.     The  upper  Avail  of  the  tympanum  was  dark  colored, 

Fig.  86. 


The  lower  osseous  wall  of  the  Tympanum  incomplete,  so  as  to  allow  of  a  communication 
between  the  Tympanic  Cavity  and  the  Fossa  Jugularis. 

and  the  thick  mucous  membrane  Avas  seen  beneath  it.  The  tympa- 
nic mucous  membrane  was  very  thick,  and  of  a  dark  purple  color, 
its  vessels  being  distended.  The  upper  part  of  the  tympanum  was 
so  filled  by  this  thick  membrane,  that  the  scrofulous  matter  and  pus 
were  retained  by  it.  The  scrofulous  matter  itself  Avas  composed  of 
fine  granules  of  epithelial  cells,  and  of  very  fine  crystals,  which  latter 
were  stated  by  Dr.  Garrod  to  consist  of  phosphate  of  ammonia  and 
magnesia.  The  stapes  was  disarticulated  from  the  incus,  and  the 
ossicles  were  concealed  by  the  thick  mucous  membrane.     The  loAver 

Fig.  87. 


The  orifice  seen  from  the  Jugular  Fossa. 


osseous  Avail  also  Avas  thin  and  of  a  red  color,  and  presented  an  orifice 
which  allowed  of  a  communication  between  the  tympanum  and  the 
fossa  jugularis. 


THE     CAVITY    OF    THE    TYMPANUM.  287 

This  case  is  especially  interesting,  from  the  fact  that  the  disease 
had  extended  downwards  to  the  lower  osseous  wall,  as  Avell  as  up- 
wards. The  lower  wall  of  the  tympanum  is  frequently  formed  by  a 
thin  layer  of  bone,  Avliich  separates  it  from  the  fossa  jugularis.  In 
many  instances  this  osseous  lamina  is  deficient  in  parts,  and  the 
outer  surface  of  the  mucous  membrane  of  the  tympanum  is  in  con- 
tact with  the  jugular  vein.  Disease  may  thus  be  propagated  from 
the  tympanic  cavity  to  the  jugular  vein. 


CHAPTER   XIII. 

THE    CAVITY  OF   THE  TYMPANUM   [concluded). 

a.  RIGIDITY  OP  THE  MUCOUS  MEMBRANK — CAUSE  OF  DEAFNESS  IX  ADVANCING  YEARS — 
TREATMENT — CASES.  b.  THE  FORMATION  OF  BANDS  OF  ADHESION.  C.  ANCHYLOSIS  OF 
THE  STAPES  TO  THE  FENESTRA  OVALIS — PATHOLOGICAL  OBSERVATIONS — TREATMENT 
CASES.  (L  DISCONNECTION  OF  THE  INCUS  AND  STAPES — PHYSIOLOGICAL  OBSER- 
VATIONS— PATHOLOGICAL  OBSERVATIONS — CASES. 

The  mucous  membrane  of  the  tympanum  may  be  subject  to 
chronic  inflammation,  complicated  or  not  with  rheumatism,  at  any 
period  of  life,  and,  if  neglected,  this  is  liable  to  terminate  in  a  rigid 
state  of  the  membrane ;  so  that  the  ossicles  become  bound  together 
more  firmly  than  is  natural.  In  advanced  years,  this  rigid  condition 
seems  to  take  place  without  any  symptom  of  inflammation.  The 
membrana  tympani  also  partakes  of  this  rigid  condition,  and,  what 
is  of  far  greater  importance,  the  base  of  the  stapes  may  become 
much  more  firmly  fixed  to  the  border  of  the  fenestra  ovalis  than  is 
natural.  As  a  consequence,  the  membrane  of  the  fenestra  rotunda 
and  the  fluid  of  the  labyrinth  participate  in  this  fixed  condition. 
This  afiection  is  less  prevalent  in  the  young  than  in  the  adult,  in 
Avhom  it  is  liable  to  occur  after  repeated  attacks  of  cold,  whether 
with  pain  or  not.  It  is,  however,  most  frequent  in  persons  ad- 
vancing in  life,  and  may,  in  fact,  be  considered  as  the  disease  which 
causes  deafness  in  advancing  years.  The  generally  received  opinion 
that  in  this  kind  of  deafness  tlie  nervous  system  is  at  ftiult,  is  mani- 
festly incorrect,  as  proved  by  the  symptoms,  and  by  the  mode  of 
relief  found  beneficial. 

The  diagnosis  of  this  aifection  is  far  from  being  diflicult ;  although, 
as  will  be  seen,  it  offers  very  little  to  guide  the  medical  man,  except 
the  history  of  the  case.  Thus,  there  is  very  often  little  or  no 
opacity,  or  even  dulness,  of  the  membrana  tympani ;  the  Eustachian 
tube  too  is  pervious,  and  the  air  enters  naturally.    Not  unfrequently, 


THE    CAVITY    OF    THE    TYMPANUM.  289 

ho-\vever,  the  membrana  tympani  shows  signs  of  chronic  inflam- 
mation, in  hypertrophy  and  a  greater  concavity  than  natural  ;  -while 
the  air,  when  forced  into  the  tympanum,  enters  it  with  a  dull  flap- 
ping sound  instead  of  the  normal  crackling.  Sometimes  on  forcing 
the  air  into  the  cavity  very  suddenly,  a  greatly  louder  crackling 
than  is  natural  is  heard ;  and  the  patient  occasionally  hears  better 
for  a  short  time  subsequent  to  the  operation.  A  symptom  of  con- 
siderable importance  in  forming  a  diagnosis,  is  the  peculiar  character 
of  the  deafness.  Many  patients  will  most  distinctly  hear  a  single 
voice,  although  low,  but  arc  puzzled  to  hear  anything  distinctly 
Avhen  two  or  more  persons  arc  speaking ;  others  hear  the  voice,  but 
cannot  discriminate  the  words ;  others  again  can  hear  slow  conver- 
sation, but  cannot  follow  it  when  rapid.  These  symptoms  indicate 
that  the  adapting  power  of  the  ear,  dependent,  as  already  shown, 
upon  the  ossicles  and  their  muscles,  is  at  fault.  But  the  history  of 
the  case,  showing  it  to  be  one  of  slow  hardening  of  the  tympanic 
mucous  membrane,  together  with  the  absence  of  all  those  symptoms 
which  render  it  liable  to  be  confounded  with  other  diseases,  as 
nervous  deafness,  obstruction  of  the  Eustachian  tube,  &c.,  are  usually 
sufficient  to  enable  an  attentive  observer  to  form  a  correct  diagnosis. 
Treatment. — It  is  highly  important  to  inquire  whether  any  reme- 
dial measures  can  be  suggested  which  will  tend  to  diminish  a  rigid 
state  of  the  mucous  membrane,  and  consequently  improve  the  power 
of  hearing.  Practical  experience  induces  me  to  believe  that  not 
only  may  the  thick  membrana  tympani  be  relieved,  but  the  thick- 
ened mucous  membrane  be  so  reduced  as  to  off'er  but  little  impedi- 
ment to  the  function  of  hearing. 

The  most  suitable  application  for  this  purpose  which  has  been 
tried  by  me,  is  that  of  a  solution  of  nitrate  of  silver,  of  a  strength 
varying  from  half  a  drachm  to  a  drachm  of  the  salt  to  an  ounce  of 
distilled  water.  Proceeding  from  the  exterior  orifice  of  the  meatus 
externus,  the  passage  may  be  touched  to  an  extent  varying  from 
one-half  to  two-thirds  of  its  length  every  third  or  fourth  day.  In 
some  cases  the  membrana  tympani  also  may  be  Avashed  with  a  solu- 
tion of  this  salt  of  six  i^rains  to  the  ounce.  "When  the  noises  are 
loud,  and  the  symptoms  indicate  much  congestion  in  the  ear,  leeches 
should  be  applied  immediately  heJow.,  not  behind  the  ears;  and  where 
there  is  irritation  of  the  external  tube,  an  ointment,  composed  of 
half  a  drachm  of  pulvis  cantharidis  added  to  an  ounce  of  simple 

19 


290  THE     DISEASES     OF     THE     EAR. 

ointment,  and  applied  behind  the  ear,  either  daily  or  every  other 
day,  will  be  found  beneficial. 

The  administration  of  alterative  doses  of  pilula  hydrargyri,  hy- 
drargyrum cum  creta,  or  the  hydrargyri  bichloridum,  is  very  useful; 
but  it  should  ahvays  be  recollected  that  these  doses  ought  to  be  so 
proportioned  as  not  to  produce  debility  or  any  other  unpleasant 
symptom ;  in  other  Avords,  so  gentle  should  be  the  alterative  that  no 
sensation  should  suggest  to  the  patients  that  they  are  under  a  course 
of  medicine. 

In  addition  to  the  medicines  described,  patients  should  be  cautioned 
to  avoid  warm  rooms  and  sitting  very  near  the  fire  ;  daily  exercise, 
and,  where  possible,  on  foot,  should  be  taken  in  the  open  air,  to- 
gether with  a  warm  bath  every  week  or  ten  days.  This  course  of 
treatment  has  been  productive  of  the  greatest  advantage  in  several 
cases  of  deafness  of  a  most  unpromising  character.  Some  of  the 
cases  about  to  be  cited  are  those  of  patients  who  attributed  their 
failure  of  hearing  to  old  age. 

The  treatment  pursued  b}"  continental  surgeons  in  cases  of  rigidity 
of  the  tympanic  mucous  membrane,  has  been  the  injection  of  air  by 
means  of  the  Eustachian  catheter.  There  can  be  no  doubt  that  tem- 
porary benefit  in  these  cases  sometimes  follows  the  use  of  the  air- 
douche,  as  well  as  the  act  of  forcing  the  air  into  the  tympanic 
cavity,  by  the  patient  holding  the  nose  while  he  attempts  a  forcible 
expiration.  But  the  very  temporary  character  of  this  benefit,  and 
its  occurrence  in  only  a  few  cases  does  not  induce  me  to  recommend 
the  performance  of  an  operation  ;  in  fact,  a  forcible  expiration  by 
the  patient  usually  answers  equally  well.  On  this  subject  I  may 
quote  the  following  judicious  remarks  from  the  article  on  the  Dis- 
eases of  the  Ear,  in  the  Cyclopaedia  of  Surgery,  by  Mr.  "Wharton 
Jones, — an  article  characterized,  as  are  all  his  Avorks,  by  the  most 
careful  observation  and  patient  research.  He  Avrites  :  "  According 
to  Kramer's  '  Tabular  View  of  the  Frequency  and  Curability  of 
Diseases  of  the  Ear,'  out  of  three  hundred  cases  of  diseases  of  the 
ear  of  all  kinds,  tAvo  hundred,  in  round  numbers,  required  the  air- 
douche  to  assist  the  diagnosis,  but  about  thirty  only  Avere  impro- 
vable or  curable  by  it.  Of  the  remaining  one  hundred  and  seventy 
about  thirty  arc  put  doAvn  as  cured,  and  about  fifty  as  relieved,  by 
the  injection  of  vapors  of  acetic  ether ;  this  treatment  having  been 
continued  for  months.  Of  the  remainder,  eighty  Avere  considered 
incurable  from  the  first,  and  not  treated  further  than  Avas  necessary 


THE    CAVITY    OF    THE    TYMPANUM.  291 

for  exploration,  I  suppose  ;  the  rest  remained  rebellious  to  treatment. 
Dr.  Kramer  does  not  tell  us  how  permanent  his  cases  were.  It  will 
be  seen  from  the  above  statement  of  the  results  of  Itard's  expe- 
rience, and  also  from  what  I  have  related  of  my  own,  that  the  ad- 
vantage gained  is  seldom  permanent." 

Case  1.  lUgidity  of  tlie  tympanic  mucous  membrane. — The  Rev. 
jNI.  ^L,  ?et.  70,  consulted  me  in  1855,  on  account  of  an  increasing 
dulness  of  hearinjr,  Avhicli  caused  him  much  inconvenience,  as  he 
could  not  hear  general  conversation.  It  had  come  on  very  gra- 
dually, without  pain,  noises,  or  any  unpleasant  sensation,  beyond 
that  of  a  feelincr  of  heaviness  in  the  ears.  The  deafness  is  increased 
by  a  cold,  but  not  by  fatigue.  On  examination.,  each  membrana 
tympani  was  seen  to  be  less  translucent  than  natural ;  and  though 
the  Eustachian  tube  was  natural,  the  air  entered  the  tympanic  cavity 
in  a  puff  instead  of  producing  a  faint  crepitation.  The  treatment 
consisted  in  keeping  up  a  slight  irritation  by  means  of  a  vesicating 
plaster  behind  each  ear,  and  in  giving  the  bichloride  of  mercury  in 
doses  of  one-thirtieth  of  a  grain,  using  also  a  stimulating  gargle. 
This  treatment  was  continued,  with  intermission  of  the  mercury,  for 
a  week  at  the  end  of  each  fortnight,  for  four  months.  At  the  expi- 
ration of  that  time,  the  hearing  power  was  greatly  improved,  and 
the  patient  wrote  to  me  as  follows : — "  I  have  not  recovered  the 
quick  hearing  of  early  life,  which  a  man  in  his  TOtli  year  has  no 
right  to  have ;  but  I  hear  comfortably,  and  I  am  freed  from  that 
dunny  sensation  as  if  sounds  came  through  a  damp  cloth." 

Case  II. — R.  B.,  Esq.,  aged  80,  in  tolerable  health,  consulted  me 
on  29th  of  March,  1844,  on  account  of  deafness  in  both  ears.  He 
stated,  that  three  years  before,  the  power  of  hearing  began  gra- 
dually to  decline  in  the  right  ear,  and  had  continued  to  do  so  up  to 
the  time  of  consulting  me;  that  about  six  months  previously  the  left 
ear  had  been  similarly  affected  ;  and  that  his  deafness  had  so  much 
increased  as  to  disable  him  from  hearing  the  voice  without  tlie  aid 
of  a  speaking-trumpet.  He  was  unable  to  assign  any  cause  for  the 
deafness.  On  examination.,  the  membrana  tympani  in  each  ear  was 
observed  to  be  dull  and  opalescent ;  and  although  by  aid  of  the 
otoscope  the  air  was  heard  to  pass  into  the  tympanic  cavities,  yet  it 
did  so  with  the  bubbling,  crackling  sound,  indicating  obstruction. 
Two  grains  of  pilula  hydrargyri  were  ordered  to  be  taken  every 
night,  and  a  stimulating  liniment  to  be  applied  around  and  below 
the  ears.     This  plan  having  been  persevered  in  for  about   three 


292  THE    DISEASES     OF    THE    EAR. 

weeks,  and  some  slight  improvement  experienced,  the  patient  was 
directed  to  take  one  grain  of  liydrargyrum  cum  creta  daily.  At  the 
end  of  two  months  this  gentleman  recovered  his  hearing,  and  gave 
up  the  use  of  the  speaking-trumpet. 

Case  III. — J.  P.,  Esq.,  aged  64,  consulted  me  in  July,  1845. 
During  the  last  four  or  five  years  the  right  ear  has  been  growing 
deaf,  and  the  deafness  has  now  so  far  advanced  as  to  render  the  ear 
useless  to  him.  Has  been  suffering  from  a  cold  for  a  few  days, 
during  Avhich  there  has  been  a  sensation  of  singing  and  of  vibration 
in  the  head  and  ears,  accompanied  with  deafness.  In  each  ear  there 
was  a  large  collection  of  wax,  on  the  removal  of  which  the  symp- 
toms somewhat  abated.  The  membrana  tympani  of  both  ears  was 
white.  Air  passed  freely  into  the  tympanic  cavities.  The  fifteenth 
of  a  grain  of  hydrargyri  bichloridum  thrice  a  day  was  prescribed, 
and  counter-irritation  around  the  ears.  In  the  course  of  six  weeks 
the  patient  had  perfectly  recovered. 

Case  IV. — Lady  R.,  aged  G2,  consulted  me  in  December,  1848, 
for  a  deafness  which  had  come  on  during  the  preceding  month,  and 
gradually  increased,  till,  by  the  time  I  saw  her,  it  was  requisite  to 
speak  loud  and  close  to  the  ears.  The  deafness  had  first  been  per- 
ceived after  a  cold,  and  was  accelerated  by  an  attack  of  influenza. 
The  feeling  in  the  right  ear  Avas  that  of  a  veil  hanging  over  it.  In 
each  ear  the  membrana  tympani  Avas  white,  and  air  passed  freely 
into  the  tympanic  cavities.  The  treatment  pursued  consisted  in  the 
application  of  a  solution  of  argenti  nitras  to  the  outer  half  of  the 
external  meatus ;  beginning  Avith  the  strength  of  half  a  drachm  of 
the  salt  to  an  ounce  of  distilled  Avater,  afterAvards  increasing  it  to 
double  that  strength.  This  course  of  proceeding,  coupled  Avitli  the 
administration  of  alterative  doses  of  pilula  hydrargyri,  effected  so 
great  an  improvement,  that  in  tAvo  months  this  lady  had  no  difficulty 
in  hearing  in  ordinary  society. 

Case  V. — Mrs.  A.  T.,  aged  67,  consulted  me  in  April,  1845. 
She  stated,  that  Avhen  eight  years  of  age,  she  fell  down  on  the  left 
ear,  and  had  been  deaf  of  that  ear  ever  since.  About  four  years 
ago  loud  internal  noises  disturbed  the  right  ear,  and  increased  to  so 
distressing  a  degree,  that  this  lady  felt  as  if  she  Avere  continually 
travelling  in  a  carriage  OA^er  gravel ;  and  at  times  a  loud  explosion 
would  be  heard,  succeeded  by  acute  pain.  She  can  scarcely  hear 
her  own  voice,  and  is  obliged  to  use  a  trumpet  in  society.  The  ears 
seem  to  her  stopped  up  Avith  pegs.     She  attributes  this  deafness  to 


THE     CAVITY     OF    THE    TYMPANUM.  293 

a  close  attendance  in  the  sick-room  of  her  husband  durino;  a  long 
illness. 

Right  car. — Membrana  tympani  concave,  and  evidently  nearer 
to  the  promontory  than  natural ;  and  the  membrane  is  so  white  that 
the  malleus  is  not  distinguishable.  Left  ear. — Membrana  tympani 
has  been  entirely  removed  by  ulceration. 

Treatment. — In  the  first  instance  leeches  were  placed  imme- 
diately below  the  ear  ;  tincture  of  iodine  was  applied  to  the  external 
meatus  of  the  right  car  ;  and  three  grains  of  pilula  hydrargyri  were 
given  every  night. 

June  3d. — Feels  much  better ;  has  less  confusion  in  the  head, 
and  more  confidence  in  herself. 

June  15th. — The  noises  are  so  much  diminished  that  she  is  no 
longer  troubled  by  them  ;  is  feeling  stronger  and  better,  and  the 
hearing  improves. 

Case  VI. — J.  C,  Esq.,  aged  64,  consulted  me  in  November,  1844. 
His  father  became  deaf  at  the  age  of  fifty,  and  he  has  a  sister  deaf. 
About  a  year  ago,  he  found  that  he  was  deaf  in  the  left  ear ;  might 
have  been  deaf  a  longer  time ;  but  at  the  period  mentioned,  sing- 
ing commenced  in  the  left  ear,  which  has  continued  without  inter- 
mission ever  since.  Occasionally  it  is  much  diminished.  The  noise 
and  deafness  and  are  much  worse  during  a  cold.  The  right  ear  is 
not  so  bad  as  the  left.  When  he  closes  the  right  ear,  he  cannot 
hear  any  sound  naturally. 

Ixight  ear. — ]Mcmbrana  tympani  opaque,  and  the  handle  of  the 
malleus  only  just  discernible.  When  air  is  forced  into  the  tym- 
panum it  can  be  heard  by  the  otoscope  entering  it  in  a  series  of 
small  pufis.  After  the  air  has  been  forced  into  the  tympanum,  a 
crackling  sensation  is  experienced.     Hearing  distance  two  inches. 

Left  ear. — Membrana  tympani  white ;  handle  of  malleus  indis- 
cernible; air  enters  the  tympanum  in  a  short  pufi".  Hearing  dis- 
tance absolute  contact. 

For  this  gentleman  two  grains  of  the  pilula  hydrargyri  were 
prescribed,  to  be  taken  every  night ;  and  tincture  of  iodine  Avas 
applied  behind  the  ears.  In  the  course  of  three  months  I  saw  him 
again,  and  found  the  hearing  decidedly  improved ;  the  noises  also 
had  diminished. 

Case  YII.— Mrs.  R.  N.,  aged  64,  consulted  me  August  2d,  1844. 
For  the  preceding  four  or  five  months  deafness  had  been  coming  on, 
and  had  lately  so  much  increased  that  she  finds  it  difficult  to  hear  any 


294  THE     DISEASES    OF    THE     EAR. 

conversation.  Has  for  several  years  been  subject  to  occasional  dul- 
ness  of  hearing.  The  present  deafness  was  apparently  produced  by 
an  attack  of  cold,  which  left  a  sensation  of  fulness  in  both  ears. 
The  membrana  tympani  of  each  ear  is  quite  white. 

Treatment. — One-twentieth  of  a  grain  of  hydrargyri  bichloridum, 
in  conjunction  with  vinum  ferri,  was  administered  thrice  a  day.  The 
dose  of  bichloride  Avas  subsequently  increased  to  one-sixteenth  of  a 
grain,  and  a  solution  of  argenti  nitras,  half  a  drachm  of  the  salt  to 
an  ounce  of  distilled  water,  was  applied  to  the  outer  half  of  the  ex- 
ternal meatus.  In  the  course  of  three  months  this  patient  recovered 
her  hearing,  and  has  remained  quite  well  ever  since. 


ih.)    MEMBRANOUS    BANDS    IN   THE   TYMPANIC    CAVITY. 

Membranous  bands  are  formed  in  every  part  of  the  tympanic 
cavity,  connecting  together  the  ossicles,  and  attaching  them  to  the 
walls  of  the  tympanum  and  to  the  membrana  tympani.  In  cases 
where  these  bands  are  lax,  it  is  probable  that  the  movements  of  the 
ossicles  are  not  impaired,  and  that  there  is  no  diminution  of  the 
power  of  hearing.  In  the  majority  of  instances,  however,  these 
membranous  bands  are  so  firm  and  unyielding  as  to  cripple  the 
movements  of  the  bones  to  which  they  are  affixed.  On  reference 
to  the  table  it  will  be  seen  that  these  membranous  bands  most 
usually  connect  the  stapes  with  the  promontory,  and  thus  produce 
one  species  of  anchj^losis  of  that  bone.  These  adhesions  originate 
either  from  the  effusion  of  fibrin  from  the  surface  of  the  membrane, 
and  its  conversion  into  a  firm  and  vascular  membrane,  or  from  the 
circumstance  that  when  the  mucous  membrane  is  much  hypertrophied, 
there  is  an  adhesion  of  the  portions  of  it  which  are  in  contact,  and 
the  neighboring  parts  are  drawn  into  bands,  when  the  membrane 
subsides  to  its  normal  condition. 

Care  should  be  taken  to  distinguish  between  bands  formed  of 
organized  membrane,  and  those  Avhicli  are  produced  by  dried  mucus, 
as  pointed  out  by  Mr.  Ilinton  in  the  paper  before  alluded  to. 

Let  me  now  relate  the  results  of  some  dissections  of  cases  in 
which  these  bands  were  found. 

Case  I.  Considerable  hardness  of  hearing  for  six  years  ;  hands  of 
adhesion  in  the  cavitij  of  the  tympanum. — Mrs.  L.  died  in  December, 
1848,  at  the  age  of  87,  from  a  gradual  decline  of  the  vital  powers. 


THE     CAVITY    OF    THE    TYMPANUM.  295 

Until  the  age  of  oO,  she  had  no  symptoms  of  derangement  of  the 
function  of  hearing  ;  but  about  that  period  slie  was  in  tlie  habit  of 
taking  "  cephalic  snuff,"  Avhich  she  thought  produced  a  buzzing 
sensation  in  her  ears,  a  symptom  which  disappeared  as  soon  as  the 
use  of  the  snuff  was  discontinued.  At  tliat  })eriod  there  was  no 
sign  of  deafness ;  but  about  the  age  of  81,  she  perceived  that  the 
sense  of  hearinn;  was  becomin<2;  blunted.  From  that  time  deafness 
gradually  and  very  slowly  increased,  attended  now  and  then  with 
noises  in  the  ears.  The  deafness  would  be  temporarily  increased 
by  a  cold,  but,  as  that  vanished,  the  usual  amount  of  hearing 
returned.  During  the  last  year  of  her  life  the  disease  made  but 
little  progress,  though  the  deceased  was  obliged  to  use  a  speaking- 
trumpet  for  the  purpose  of  conversation.  It  was  observed  that  the 
sense  of  hearing  became  much  more  acute  during  the  last  few  days 
of  her  life.  This  lady  took  very  little  exercise  during  the  ten  years 
preceding  her  death,  but  kept  within  doors,  and  sat  in  a  warm 
room  the  greater  part  of  every  day.  She  was  troubled  with  a 
chronic  inflammation  of  the  mucous  membrane  of  the  eyelids, 
lachrymal  sacs,  and  nasal  ducts.  It  is  worthy  of  notice  that  this 
lady  had  two  sisters,  one  of  whom  died  at  the  age  of  90.  She  was 
a  very  active  person  nearly  up  to  the  period  of  her  death,  and  was 
but  slightly  deaf.  The  other  sister,  at  the  age  of  89,  is  extremely 
deaf,  and  has  been  confined  to  her  room  for  years. 

Dissection.  Right  ear. — The  external  meatus  was  dry  and  de- 
prived of  cerumen.  The  membrana  tympani  has  its  fibrous  layer 
slightly  thickened  and  white,  and  is  more  concave  than  natural. 
Tympanic  cavity. — The  mucous  membrane   appears  to  be  healthy, 

Fig.  88. 


Membranous  Bands  connecting  the  Ossicles. 

and  not  thicker  than  natural,  but  there  are  bands  of  adhesion  by 
which  the  ossicula  are  connected  together  and  with  the  walls  of  the 
tympanum.     These  bands  of  adhesion  may  be  divided  into  two  dis- 


296  THE     DISEASES     OF     THE     EAR. 

tinct  sets  ;  one  placed  between  the  incus  and  the  innei*  "wall  of  the 
tympanum  and  stapes,  and  the  other  connecting  the  head  of  the 
malleus  and  the  body  of  the  incus  with  the  external  wall  of  the 
tympanum.  The  first-named  set  consists  of  two  portions,  of  which 
the  one,  measuring  half  a  line  from  above  downwards,  and  three- 
quarters  of  a  line  from  without  inwards,  connects  the  anterior  part 
of  the  long  process  of  the  incus  with  that  part  of  the  wall  of  the 
tympanum  which  is  posterior  to  the  fenestra  oralis.  This  band  is 
connected  by  several  smaller  ones  to  the  superior  surface  of  the 
stapes,  and  also  to  a  fine  membrane  which  connects  the  two  crura 
of  the  latter  bone.  These  small  bands  are  so  firm  and  so  tightly 
stretched  between  the  stapes  and  the  larger  band,  and  between  the 
incus  and  the  inner  wall  of  the  tympanum,  as  to  keep  the  stapes 
more  fixed  than  natural.  There  are  also  adhesions  between  the 
upper  surface  of  the  crura  of  the  stapes  and  the  margin  of  the  fossa 
fenestras  ovalis.  The  outer  portion  of  this  band  extends  from  the 
posterior  part  of  the  long  process  of  the  incus  to  the  inner  wall  of 
the  tympanum,  posterior  to  that  just  described :  this  band  is  also 
firm  and  tense.  The  second  set  of  adhesions  passes  from  the  head 
of  the  malleus  and  the  body  of  the  incus  directly  outwards,  con- 
necting them  with  the  osseous  walls  of  the  tympanum,  superior  and 
posterior  to  the  attachment  of  the  membrana  tympani.  It  is  in- 
teresting to  consider  what  efiect  these  bands  must  have  had  upon 
the  ossicula  and  membrana  tympani  during  life.  Those  Avhich  sur- 
round the  stapes  and  connect  it  with  the  fossa  fenestra©  ovalis,  must 
have  impeded  the  movements  of  the  stapes ;  and  those  which  con- 
nect  the   long   process  of  the   incus  with  the   inner   wall  of  the 

Fig.  89. 


/ 
Membranous  Bands  connecting  the  Ossicles  to  the  Promontory.     (Magnified.) 

tympanum,  by  pulling  that  process  inwards,  would  probably  have 
been  the  means  of  pressing  the  stapes  towards  the  vestibular  cavity. 
The  effect  of  the  adhesions  between  the  bodies  of  the  malleus  and 


THE    CAVITY    OF    THE    TYMPANUM.  297 

incus,  and  the  outer  -wall  of  the  tympanum,  would  seem  to  have 
been  to  draw  those  parts  outwards,  and,  in  consequence,  their 
inferior  extremes  iuAvards.  This  action  upon  the  malleus  is  ap- 
parent, and  may  account  for  the  greater  concavity  of  the  mend^rana 
tympani  externally ;  it  having  been  carried  inwards  with  the  long 
process  of  the  malleus  and  being  very  tense.  The  bone  of  the 
stapes  is  also  fixed  more  firmly  than  is  natural  to  the  margin  of  the 
fenestra  ovalis.  The  membrane  of  the  fenestra  rotunda  appears  to 
be  in  a  normal  state.  The  membranous  labyrinth  is  healthy  ;  and 
except  that  there  is  rather  more  black  pigment  than  usual  in  the 
cochlea  of  the  left  ear,  it  is  in  a  similar  condition  to  the  right  ear, 
and  presents  adhesions  connecting  the  ossicula. 

Case  II.  3Iemhrana  tT/mjmni  very  concave  externally:  hands  of 
adhesion  connecting  the  ossicula  together  and  to  the  tympanic  walls. — 
Mrs.  F.  0.,  died  of  gangrena  senilis,  at  the  age  of  62.  She  had 
been  deaf  for  a  considerable  period  previous  to  her  death,  especially 
in  the  left  ear. 

Dissection.  Right  ear. — The  membrana  tympani  is  unusually 
concave  externally,  and  the  central  part  of  its  internal  surface  is 
not  more  than  a  quarter  of  a  line  from  the  promontory ;  it  is  also 
rather  opaque  in  parts,  especially  at  its  circumference ;  and  its  in- 
ternal layer  is  white,  and  slightly  hypertrophied.  The  mucous 
membrane  of  the  tympanic  cavity  is  rather  thicker  and  more  vascular 
than  natural,  and  is  very  tough.  A  firm  band  of  adhesion  connects 
the  cervix  of  the  malleus  with  the  long  process  of  the  incus,  and 
another  membranous  band  of  adhesion  connects  the  anterior  surface 
of  the  long  process  of  the  incus  with  the  promontory  and  with  the 
stapes,  which  latter  bone  it  completely  envelopes.  The  tensor  tym- 
pani muscle  is  smaller  than  natural. 

Left  ear. — Although  the  surface  of  the  membrana  tympani  is 
smooth,  it  is  white  around  the  line  of  attachment  of  the  malleus ; 
the  bloodvessels  are  enlarged  and  much  distended  with  blood.  The 
membrana  tympani  is  more  concave  externally  than  natural.  /The 
cavitas  tympani  is  three  parts  filled  with  a  thick,  tenacious,  white 
mucus,  which  is  partly  the  cause  of  the  white  appearance  of  the 
membrana  tympani,  though  the  inner  layer  of  the  membrana  tym- 
pani being  opaque  and  white,  aids  in  producing  this  effect.  The 
mucous  membrane  lining  the  tympanum  is  thick  and  very  vascular. 

It  is  not  possible  to  distinguish,  during  life,  between  the  cases  of 
rigidity  of  the  tympanic  mucous  membrane,  and  those  of  adhesions 


298  THE     DISEASES     OF     THE     EAR. 

in  tlic  tympanic  cavity  ;  but  as  the  treatment  in  both  cases  is  the 
same,  the  distinction  is  not  of  much  importance. 


(c.)    ANCHYLOSIS    OF    THE    STAPES   TO    THE   FENESTRA    OVALIS. 

In  tlie  published  catalogue  of  the  preparations  contained  in  my 
museum,  I  have  described  one  hundred  and  thirty-six  specimens  of 
anchylosis  of  the  base  of  the  stapes  to  the  fenestra  ovalis  :  and  these 
specimens  form  the  basis  from  which  the  pathology  of  this  articula- 
tion has  been  studied. 

In  a  tabular  view  of  the  morbid  appearances  found  in  1149  dis- 
eased ears,  published  originally  in  the  Tratisactions  of  the  Royal 
Medical  and  Chirurgicai  Society^  and  afterAvards  as  an  appendix  to 
the  catalogue  of  my  museum,  fifty-three  specimens  of  membranous 
anchylosis  are  described,  specimens  in  which  the  stapes  was  attached 
more  firmly  than  natural  to  the  circumference  of  the  fenestra  ovalis ; 
that  is  to  say,  upon  the  stapes  being  pressed  by  a  fine  probe,  more 
than  usual  resistance  Avas  offered  before  the  stapes  moved.  Now, 
in  these  cases,  no  expansion  of  the  base  of  the  stapes,  or  of  the 
articular  surface  of  the  fenestra  ovalis,  was  observed  :  and  the  only 
inference  that  could  be  drawn  was,  that  these  Avere  cases  of  partial 
anchylosis  of  the  stapedio-A'estibular  articulation,  resulting  from 
rigidity  of  its  capsular  ligaments ;  and  I  am  disposed  to  think,  that 
this  rigidity  of  the  fibrous  tissue  is  one  of  the  earlier  and  more  re- 
mediable stages  of  anchylosis  of  this  and  other  articulations,  which, 
if  allowed  to  proceed,  ends  in  the  formidable  pathological  conditions 
knoAvn  under  the  name  of  rheumatic  arthritis,  and  Avhich  are  about 
to  be  more  particularly  described. 

The  second  morbid  change  found  in  this  articulation  is  a  simple 
expansion  of  the  articular  surfaces,  Avhile  the  structure  of  the  bone 
itself  remains,  as  far  as  can  be  ascertained,  in  a  natural  state.  This 
morbid  condition  of  the  articular  surfaces  was  found  in  forty-nine 
out  of  the  one  hundred  and  thirty-six  cases  of  anchylosis  ;  and  AAas 
distinguishable  from  membranous  anchylosis  by  the  greater  degree 
of  firmness  Avith  AA'hich  the  stapes  adhered  to  the  fenestra  ovalis,  and 
by  the  presence  of  a  distinct  tumefaction  of  one  or  other  articular 
surface,  but  generally  of  the  stapedial. 

The  third  pathological  condition  is  that  in  Adiich  the  Avhole  of  the 
base  of  the  stapes  has  become  hypertrophied,  and  assumed  a  calca- 


THE    CAVITY    OF    THE    TYiMPANUM. 


299 


reous  Avliitcness  ;  the  border  bcino;  so  miicli  enlarffed  as  to  be  im- 
pacted  within  the  fenestra  ovalis  with  that  (U^grcc  of  firmness,  that 
the  crura  arc  often  broken  from  the  base  in  the  attempt  to  withdraw 


Fig.  90. 


The  whole  of  the  Circumference  of  the  base  of  the  Stapes  anehylosed  to  the  Fenestra 
Ovalis,  the  Crura  being  detached,  and  seen  below,  a,  the  base  of  the  Stapes  ;  i,  the 
Crura  (magnified  two  diameters). 

the  hitter  from  the  fenestra  ovalis.     In  some  instances,  this  expan- 
sion of  the  base  of  the  stapes  is  accompanied  bj  its  protrusion  into 


Fig. 91. 


Base  of  the  Stapes  expanded,  and  osseous  matter  thrown  out  around  it  and  the  Crura. 
a,  the  Stapes  ;  i,  the  cavity  of  the  Vestibule  (magnified  two  diameters). 

the  cavity  of  the  vestibule  ;  still  there  appears,  even  in  these  cases, 
to  be  nothing  more  than  hypertrophy  and  condensation  of  the  normal 


300 


THE     DISEASES     OF     THE     EAR. 


osseous  structure.    This  morbid  condition  shows  itself  in  twenty-nine 
specimens. 


Fig.  92. 


Expansion  of  the  base  of  the  Stapes,  and  its  protrusion  into  the  cavity  of  the  Vestibule. 
1  (Magnified.) 

The  fourth  pathological  condition  is  that  in  which  the  base  of  the 
stapes  is  greatly  expanded,  and  ncAv  osseous  matter  is  thrown  out 

Fig.  93. 


Expansion  of  the  Vestibular  Surface  of  the  Articulation.  (Magnified  two  diameters.) 
a,  The  Upper  Margin  of  the  Stapes  free  ;  b,  the  Lower  Margin  of  the  Stapes  anchy- 
losed. 

beyond  the  natural  limit  of  the  bone,  so  as  to  connect  the  stapes 
■with  the  adjacent  parts  of  the  fenestra  ovalis  ;  a  morbid  condition 
which  is  seen  in  twenty-five  specimens. 


THE    CAVITY    OF    THE    TYMPANUM.  301 

The  fifth  pathological  condition  is  that  in  which  the  structure  of 
the  base  of  the  sta])es  undergoes  little  or  no  alteration  :  but  Avliere 
ossific  matter  is  thrown  out  at  its  circumference,  and  the  base  is 
thus  partially  or  wholly  anchylosed  to  the  fenestra  ovalis.  This 
morbid  condition  is  shown  in  twenty-one  specimens,  in  eight  of 
which  the  lower  border  only  was  anchylosed ;  there  being  a  distinct 
space  between  the  upper  margin  of  the  base  and  the  fenestra 
ovalis  :  while  in  thirteen  others,  the  whole  circumference  of  the 
base  is  firmly  anchylosed  to  the  fenestra  ovalis. 

The  sixth  pathological  condition  consists  in  the  expansion  of  the 
vestibular  surface  of  the  articulation,  and  the  effusion  of  bone  around 
the  fenestra  ovalis,  the  stapes  remaining  perfectly  healthy  ;  an  ab- 
normal condition  which  occurred  in  twelve  instances. 

The  five  morbid  conditions  last  described,  comprised  in  13G  speci- 
mens, may  be  summarily  stated  in  this  form  : — 

1.  Simple  expansion  of  the  articulating  border  of  the  base  of  the  stapes,         .     49 

2.  Expansion  of  the  articulating  border  of  the  base  of  the  stapes  with  calca- 

reous \Yhiteness  of  the  whole  base,    ........     29 

3.  Expansion  of  the  whole  of  the  base  and  effused  bone  connecting  the  two 

articulating  surfaces,        ..........     25 

4.  Osseous  matter  effused  between  the  stapes  and  fenestra  ovalis  connecting 

the  two  articulating  surfaces,   .........     21 

5.  Osseous  matter  effused  around  the  fenestra  ovalis,      .         .         .         .         .12 

136 


DIAGNOSIS   AND    PROGNOSIS. 

The  diagno.sis  of  this  aftectiou  is,  in  the  majority  of  cases,  at- 
tended with  little  difficulty,  if  the  origin  and  progress  of  the  affec- 
tion be  carefully  investigated,  and  the  organ  be  examined  with 
sufficient  accuracy.  The  symptoms,  in  fact,  of  this  class  of  disease 
are  very  similar  to  those  occurring  in  cases  of  rigidity  of  the  mucous 
membrane,  already  described.  After  a  certain  duration  of  these  symp- 
toms, sometimes  for  many  months,  the  patient  is  found  to  be  growing 
gradually  deafer  and  deafer,  frequently  without  any  other  marked 
symptom,  though  often  there  is  a  feeling  of  fulness  or  pressure  in 
the  ears,  or  a  buzzing  sound  wlien  laying  the  head  upon  the  pillow. 
The  progress  of  the  affection  is  at  first  usually  slow  ;  at  intervals  of 
two,  three,  four,  or  more  months,  the  patient  observes  the  deafness 
to  be  decidedly  on  the  increase,  though  mitigated  temporarily  per- 


302  THE    DISEASES     OF    THE    EAR. 

haps  by  his  resorting  to  very  violent  exercise,  or  by  taking  spare 
diet  or  aperient  medicines.  If  the  progress  of  this  aflFection  be  left 
unchecked,  total  deafness  results,  and  may  take  place  at  an  early 
period  of  life,  as  between  the  ages  of  twenty  and  thirty,  though 
commonly  it  does  not  happen  till  a  much  later  period.  Sometimes 
the  affection  advances  so  far  as  to  produce  a  certain  degree  of  deaf- 
ness only,  as  where  the  patient  has  to  be  addressed  in  a  loud  voice 
within  a  yard  or  two  of  his  ear,  and  then,  from  some  constitutional 
change,  no  further  progress  takes  place.  An  interesting  symptom 
frequently  met  with  in  cases  of  this  disease  is  the  momentary  im- 
provement of  the  hearing  produced  by  the  acts  of  yawning  widely, 
or  pulling  the  outer  ear,  or  pressing  the  tragus  hard  and  quickly 
against  the  orifice  of  the  meatus  ;  each  of  which  actions  is  followed 
by  a  temporary  relaxation  of  the  membrana  tympani  and  chain  of 
ossicles.  In  the  case  of  yawning,  I  am  disposed  to  believe  that  this 
relaxation  is  produced  by  the  mechanical  action  of  the  chorda  tym- 
pani nerve,  which,  being  drawn  tight,  slightly  pulls  out  the  chain 
of  ossicles.  Another  and  peculiar  symptom,  is  the  effect  produced 
by  very  loud  and  sudden  sounds,  as  in  two  of  the  appended  cases. 
In  one  of  these,  where,  doubtless,  the  stapes  Avas  fixed  by  the  expan- 
sion of  its  border,  a  loud  scream  in  the  ear  at  once  restored  the 
hearing  by,  as  it  would  seem,  suddenly  releasing  the  bone  ;  a  resto- 
ration which  lasted  for  several  days,  until,  in  fact,  the  two  again 
became  fixed  :  in  the  other,  a  very  loud  sound  of  bagpipes  in  the 
patient's  hall,  where  he  was  sitting,  so  increased  his  deafness,  that 
his  friends  were  obliged  temporarily  to  use  a  slate  and  pencil  to 
communicate  Avith  him.  This  increase  of  deafness  also  disappeared, 
and  the  patient  recovered  his  previous  amount  of  hearing. 

A  third  interesting  and  very  common  symptom  of  the  early  stages 
of  anchylosis  of  the  stapes,  is  the  loss  of  what  I  am  in  the  lial)it  of 
calling  the  adapting  power  of  the  organ.  Thus  the  patient  will  hear 
perfectly  a  single  distinct  voice,  but  a  second  voice  intermingling, 
completely  disables  him  from  hearing  either  ;  he  having  lost  the 
power  of  rapidly  adjusting  his  ear  to  suit  the  sound  of  the  voice  of 
the  person  immediately  addressing  him  to  the  exclusion  of  that  of 
the  other.  Yet  another  striking  symptom  of  the  early  stages  of  the 
affection,  is  the  necessity  of  exercising  an  act  of  sustained  volition, 
in  order  to  catch  the  sound  of  a  voice,  Avhich  ceases  to  be  perceptible 
as  soon  as  the  effect  is  relaxed.  It  has,  indeed,  happened  to  me  to 
receive  patients  Avhose  complaint  consisted  not  in  being  dull  of  hear- 


THE    CAVITY    OF    THE    TYMPANUM.  303 

ing,  since  they  could  liear  everything  said  in  a  room,  but  in  not 
being  able  to  do  this  'without  a  prolonged  cftbrt  of  attention,  the 
fatigue  of  ^hich  soon  became  intolerable.  Tiiis  latter  condition  is, 
of  course,  perfectly  explicable,  from  the  more  or  less  rigidity  of  the 
chain  of  bones  in  this  disease,  and  the  muscular  eftbrt  consequently 
required  to  move  it  and  keep  it  in  constant  motion. 

Another  symptom,  and  one  certainly  characteristic  of  the  later 
stages  of  this  afl'ection,  but  which  it  is  not  in  my  poAver  to  deny  may 
not  also  be  present  in  another  disease  of  the  ear,  is  the  immense 
improvement  to  the  hearing  which  attends  the  patient's  travelling  in 
a  carriage  over  a  hard  road,  by  which  considerable  vibration  is  com- 
municated to  his  body, — a  vibration  that  doubtless  in  a  degree 
shakes  the  chain  of  bones,  and  imparts  to  them  a  kind  of  vibratory 
movement,  which  permits  the  muscles,  Avhile  it  lasts,  so  to  act  on 
these  bones  as  to  restore  more  or  less  of  their  proper  functions  in 
adjusting  the  pressure  on  the  labyrinth. 

On  examining  the  patient,  there  is  usuall}^  abundant  evidence  of 
the  rheumatic  or  gouty  diathesis  having  been  or  being  present,  such 
as  congestion  or  tumefaction  of  the  nasal  and  faucial  mucous  mem- 
branes, and,  in  addition,  hypertrophy  of  the  tonsils  in  young  per- 
sons. On  inspecting  advanced  cases,  there  is  usually  an  absence  of 
cerumen  from  the  external  meatus,  the  result  of  the  congestion  of 
this  part  of  the  organ,  of  which  the  membranous  meatus  presents 
most  characteristic  symptoms,  in  being  red  and  so  swollen  as  gene- 
rally to  have  lost  its  oval  form  and  to  have  become,  in  parts,  con- 
stricted. Thus  the  upper  half  of  the  tube  may  retain  its  normal 
size  and  shape,  while  the  lower  may  be  reduced  to  a  narrow  fissure 
only  one-half  or  one-third  of  its  proper  dimensions.  Sometimes  this 
diminution  of  the  calibre  of  the  meatus  arises  from  a  bulging  of  the 
bone  forming  the  walls,  so  as  to  become  a  convex  protuberance ;  in 
other  instances,  these  osseous  protuberances  are  so  prominent  as  to 
gain  the  name  of  tumors,  and  as  such  they  have  been  described  in 
treating  of  the  meatus. 

The  dermis  covering  this  bone  is  usually  of  a  deep  red  color  ;  in- 
deed, as  a  rule,  the  dermoid  meatus  is  highly  congested  in  cases  of 
gouty  and  rheumatic  affections  of  the  ear.  The  condition  of  the 
mcmhrana  tympani  does  not  afford  much  aid  in  forming  a  diagnosis, 
though  as  a  general  rule,  to  which  there  are  many  exceptions,  it  is 
somewhat  more  opaque,  and  its  surface  duller  than  natural.  Often 
it  is  very  opaque,  and  white  as  parchment,  and  not  unfrequently  it 


304  THE     DISEASES     OF     THE     EAR. 

exhibits  patches  of  opacity  in  diifercut  parts.  Occasionally  the 
membrane  is  more  concave  externally  than  is  natural.  In  advanced 
cases,  like  those  where  the  base  of  the  stapes  has  become  fixed,  the 
membrana  tympani  is  rigid.  The  presence  of  this' rigidity  is,  how- 
ever, difficult  to  ascertain  by  simple  pressure  on  the  surface  ;  but 
its  existence  may  be  proved  b}''  the  use  of  the  otoscope,  while  the 
patient  either  swalloAvs  Avitli  closed  nostrils,  or  forces  the  air  into 
the  tympanic  cavity  by  blowing  the  nose  forcibly,  the  nose  and 
mouth  being  at  the  same  time  closed.  In  each  of  these  acts  the  air 
is  heard  to  enter  the  tympanic  cavity,  for  the  Eustachian  tube  in 
these  instances  is  usually  open  ;  but  in  place  of  the  fine  crackling 
sound  elicited  by  these  operations,  when  performed  on  a  healthy  ear, 
a  flapping,  or  coarse  crackling,  is  heard,  produced  by  the  air  striking 
against  the  inner  surface  of  the  unyielding  or  tense  drum.  A  yet 
further  symptom  of  this  disease  is,  that  the  patient  commonly  hears 
better  in  proportion  to  the  loudness  of  the  speaker's  voice  ;  whereas, 
in  cases  of  debility  of  the  nervous  apparatus  of  the  ear,  it  is  not  the 
loud  voice,  but  that  which  is  peculiarly  modulated  which  is  heard 
the  best,  occasionally  even  when  as  low  as  a  whisper.  In  addition 
to  the  foregoing  symptoms,  the  existence  of  anchylosis  of  the  stapes 
may  be  diagnosed  by  a  careful  attention  to  the  causes  producing  it, 
and  to  the  stages  of  its  progress,  which  offer  so  marked  a  contrast 
to  cases  of  debility  of  the  nervous  apparatus,  Avith  which  cases  of 
anchylosis  of  the  stapes  may,  doubtless,  otherwise  be  confounded. 

AVith  regard  to  the  prognosis,  it  may  be  laid  down  as  a  general 
rule,  that  so  long  as  the  affection  depends  upon  rigidity  of  the  liga- 
ments, or  upon  a  slight  expansion  of  the  basis  of  the  stapes  (and  the 
surgeon  can  judge  of  the  existence  of  these  conditions  during  life 
by  the  symptoms  being  but  little  advanced),  then  there  is  every  pros- 
pect that  considerable  amelioration  may  be  effecte<l,  and  the  patient, 
in  fact,  be  enabled  to  hear  without  any  inconvenience,  for  experience 
has  taught  me  that  a  rigid  ligament  may  be  relaxed,  and  an  expanded 
bone  be  reduced  in  size.  I  may  even  venture  on  the  further  state- 
ment, that,  judging  from  the  visible  diminution  of  the  bony  tumors 
in  the  external  meatus  under  the  influence  of  remedial  measures,  and 
taking  into  account  also  the  decided  improvement  which  at  times 
takes  place  in  cases  where,  from  the  symptoms,  there  Avas  every 
reason  to  believe  that  the  stapes  or  vestibule  had  become  similarly 
expanded,  there  can  be  but  little  doubt  that,  even  in  tlie  more  ad- 
vanced stages  of  anchylosis  by  expansion,  some  benefit  can  be  ob- 


THE    CAVITY    OF    THE    TYMPANUM.  305 

tained  by  the  use  of  remedies  which  shall  cause  the  effused  matter 
to  be  absorbed.  The  more  liopeless  cases  are  those  in  Avhich  the  op- 
posing articular  surfaces  of  the  stapes  and  vestibule  are  united  by 
ossific  matter  ;  and  at  present  I  am  unaware  of  any  means  by  which 
they  can  be  diagnosed  and  discriminated  from  cases  of  anchylosis  by 
expansion  of  the  articular  surfaces. 

Treatment. — The  treatment  in  these  cases  differs  in  no  essential 
respect  from  that  recommended  for  cases  of  rigidity  of  the  fibro- 
mucous  membrane. 

Case  I. — Mr.  W.,  aged  47,  consulted  me,  in  the  year  1848,  on 
account  of  the  state  of  his  health,  which  was  greatly  impaired  by  at- 
tacks of  rheumatic  gout  and  congestion  of  the  liver.  When  I  saw 
him,  he  Avas  so  deaf  that  lie  required  to  be  loudly  spoken  to,  within 
tlio  distance  of  a  yard  from  his  head.  His  habits  were  fur  from 
being  temperate,  as  he  indulged  freely  in  alcoholic  drinks.  The  his- 
tory of  his  deafness  was,  that  many  years  previously  he  liad  gradu- 
ally become  dull  of  hearing,  and  that  this  dulness  had  increased 
slowly  up  to  the  period  of  my  seeing  him.  The  only  occasion  upon 
which  he  had  been  temporarily  benefited,  was  on  the  removal  of  a  large 
mass  of  cerumen  from  the  meatus.  I  did  not  examine  the  ears,  as 
I  was  not  consulted  on  account  of  the  deafness ;  but  this  omission  is 
supplied  by  the  particulars  of  the  post-mortem  inspection.  After 
having  known  him  for  a  few  years,  he  died  from  an  attack  of  inflam- 
mation of  the  lungs. 

Dissection.  Might  ear. — The  meatus  externus  was  somewhat  con- 
tracted, the  lower  part  being  rough,  and  the  surface  irregular.  The 
membrana  tympani  was  thicker,  and  more  opaque  and  rigid  than 
natural ;  the  chain  of  ossicles  formed  so  solid  a  l)ridge  between  the 
membrana  tympani  and  the  vestibule,  that  considerable  pressure  on 
the  handle  of  the  malleus  at  the  outer  extremity  of  this  bridge  was 
requisite  to  produce  the  slightest  movement  of  the  chain.  In  the 
lower  part  of  the  tympanic  cavity,  a  white  deposit  adhered  to  the 
surface  of  the  bone,  and  was  so  closely  incorporated  with  tlie  fibro- 
mucous  membrane,  as  to  render  it  difficult  to  pronounce  whether  it 
was  in  the  substance  of,  or  below  the  membrjine.  The  base  of  the 
stapes  was  somewhat  expanded,  and  its  circumference  was  perfectly 
anchj'losed  to  the  fenestra  ovalis.  This  anchylosis  was  partly  effected 
by  the  expajision  of  the  bone  of  the  stapes,  and  partly  by  the  effusion 
or  prolongation  from  it,  especially  at  the  posterior  part,  of  hard  white 
matter. 

20 


306  THE     DISEASES     OF     THE     EAR. 

Left  ear. — The  meatus  externus  was  contracted,  presenting  at  its 
posterior  part  a  bulging  of  bone,  and  at  its  inferior  part  being  very 
narrow.  The  membrana  tympani  was  opaque,  and  the  chain  of 
bones  as  rigid  as  in  the  right  ear.  The  head  of  the  malleus  pre- 
sented small  nodosities,  similar  to  those  on  the  heads  of  other  bones 
affected  with  rheumatic  gout.  The  stapes  was  perfectly  anchylosed 
to  the  fenestra  ovalis  by  the  expansion  of  its  base,  and  by  the  pre- 
sence of  a  large  quantity  of  hard  white  matter  which  surrounded  it. 
The  cavity  of  the  vestibule  contained  also  a  great  deal  of  white 
matter,  similar  to  that  in  the  righf  tympanic  cavity. 

In  another  case,  somewhat  analogous  in  its  morbid  condition  to 
the  foregoing,  and  in  which  the  deafness  and  anchylosis  were  equally 
complete,  the  patient  died  with  consumption  under  the  care  of  Dr. 
Sibson,  in  St.  Mary's  Hospital,  at  the  early  age  of  20,  clearly  show- 
ing that  this  affection  is  not  necessarily  an  accompaniment  of  ad- 
vancing years. 

Case  II. — Mr.  L.  J.,  aged  90,  in  good  health,  except  that  he  suf- 
fered from  attacks  of  gout,  often  complicated  with  rheumatism. 
About  the  age  of  40,  he  found  a  dulness  of  hearing  gradually  com- 
ing on,  which  as  gradually  increased,  until,  at  the  time  I  saw  him, 
he  could  only  hear  the  voice  Avhen  loudly  spoken  to  close  to  the  head. 
This  gentleman  had  no  desire  for  any  treatment  to  be  pursued,  and 
I  merely  diagnosed  the  affection  from  the  history  of  the  case, — its 
slow,  insidious  progress,  the  absence  of  all  symptoms  of  nervous 
debility,  and  the  attacks  of  gout  with  which  the  patient  Avas  troubled. 
My  opinion,  thus  formed,  was  that  the  cause  of  the  deafness  was 
anchylosis  of  the  stapes ;  an  opinion  that  I  expressed  to  his  medical 
and  other  friends.  He  died,  some  years  after  my  first  seeing  him, 
of  gouty  inflammation  of  the  bladder,  and  the  opportunity  was 
afforded  me  of  carefully  dissecting  both  petrous  bones. 

liiglit  ear. — Meatus  externus.  At  the  posterior  and  upper  part 
there  was  a  distinct,  smooth,  and  rounded  projection  of  the  bone, 
which  extends  obliquely  from  Avithout  and  below,  inwards  and  up- 
wards, and  is  continuous  Avith  the  rough  scabrous  portion  of  bone 
which  forms  the  loAver  part  of  the  meatus  externus  at  its  orifice,  and 
is  quite  distinct  from  the  mastoid  portion  of  the  bone.  This  pro- 
jection measures  about  three  lines  from  above  dowuAvards.  At  the 
upper  part  of  the  meatus  the  bone  is  rough  and  hypertrophied. 

The  membrana  tympani  was  more  concave  externally,  and  much 
thicker  and  more  opaque  than  natural.     It  Avas  so  rigid  that  pressure 


THE     CAVITY    OF    THE    TYMPANUM.  307 

upon  the  outer  surface  of  the  malleus  by  means  of  a  fine  probe  was 
not  followed  by  any  movement  of  the  chain  of  bones.  Upon  laying 
open  the  tympanic  cavity  and  pressing  upon  the  stapes,  this  bone 
was  found  to  be  so  compactly  attached  to  the  inner  wall  of  the  tym- 
panum, that  upon  pressure  there  was  not  the  slightest  degree  of 
movement.  A  broad  membranous  quadrilateral  band  entirely  filled 
the  space  between  the  long  process  of  the  incus,  the  internal  Avail, 
the  stapes,  and  the  posterior  wall  of  the  tympanum.  On  laying 
open  the  vestibule,  the  base  of  the  stapes  was  observed  to  be  of  a 
Avhite  calcareous  aspect,  and  perfectly  united  to  the  circumference 
of  the  fenestra  ovalis  by  calcareous  matter.  The  membrane  of  the 
fenestra  rotunda  appeared  to  be  healthy,  except  that  it  Avas,  if  any- 
thing, slightly  thicker  than  natural. 

Left  car. — The  meatus  externus  presented  a  bulging  similar  in 
shape  and  direction  to  that  in  the  right  ear,  though  somewhat  larger. 
The  membrana  tympani  Avas  thicker  and  more  rigid  than  natural, 
but  not  more  concave  externally  than  usual.  The  difference  in  the 
degree  of  concavity  of  this  membrane  in  the  tAvo  ears  Avas  so  decided, 
that  the  inner  surface  of  its  central  part,  in  the  right  ear,  Avas  one- 
third  nearer  to  the  inner  Avail  of  the  tympanum  than  it  Avas  in  the 
left  ear.  The  stapes  was  firmly  fixed,  and  its  base,  Avhen  the  A^es- 
tibule  was  opened,  Avas  found  to  be  expanded  and  completely  anchy- 
losed  to  the  fenestra  ovalis. 

Case  III. — Mr.  T.  L.  J.,  aged  50,  of  a  gouty  diathesis,  the  son 
of  the  above  patient,  consulted  me,  in  1852,  on  account  of  gradually 
increasing  deafness.  When  I  saAv  him,  he  had  to  be  loudly  spoken 
to  Avithin  the  distance  of  a  yard  of  the  head.  He  stated  that  the 
deafness  had  come  on  very  gradually  Avithout  any  pain  or  uneasy 
feeling  in  the  ears,  and  that  no  relief  Avas  ever  experienced  except 
from  taking  long  walks,  and  perspiring  A^ery  copiously.  On  exam- 
ination, the  membrana  tympani  in  each  ear  Avas  somcAvhat  opaque, 
and  the  Eustachian  tube  pervious ;  the  air  entering  in  a  loud  puff. 
The  history  of  the  case,  and  its  similarity  to  that  of  the  father, 
made  me  sure  that  the  cause  of  deafness  was  anchylosis  of  the  stapes. 
I  laid  down  certain  rules  to  be  carried  out,  but  on  account  of  the 
sedentary  nature  of  the  patient's  occupation,  they  could  not  be  ob- 
served; attacks  of  gout  became  more  frefpu'iit,  and  total  deafness 
ensued. 

Case  IV. — Mr.  N.  C,  aged  GO,  a  man  of  intemperate  habits, 
gradually  became  deaf  at  the  age  of  24.     The  deafness  sloAvly  in- 


308  THE     DISEASES     OF     THE     EAK. 

creased  to  the  day  of  his  death,  which  took  place  at  the  age  of  60, 
from  an  attack  of  bronchitis.  There  was  hereditary  deafness  in  this 
gentleman's  family,  several  sisters  and  brothers  becoming  slowly 
deaf  about  the  same  age  as  did  this  patient.  For  some  time  previous 
to  his  death,  the  patient's  right  ear  was  useless,  but,  by  means  of  a 
trumpet,  he  could  manage  to  hear  loud  conversation  addressed  to 
him  in  the  left. 

Dissection  of  right  car. — (This  dissection  was  made  by  Mr.  A. 
Nopper,  who  kindly  forwarded  to  me  the  specimen  and  his  notes.) 
Membrana  tympani  more  opaque  than  natural.  Numerous  transpa- 
rent, membranous  bauds  traverse  the  tympanic  "cavity.  The  ossicles 
were  in  a  healthy  state,  with  exception  of  the  stapes,  the  crura  of 
which  had  disappeared.^  The  fenestra  ovalis  was  closed  by  the  base 
of  the  stapes,  which  projected  slightly  into  the  cavity  of  the  vesti- 
bule. In  the  vestibular  cavity  surrounding  the  fenestra  ovalis,  was 
a  white  mass  of  bone,  which  formed  an  annular  protuberance  around 
the  interior  two-thirds  of  the  fenestra  ovalis. 

Case  y.  Partial  anchylosis  of  the  staj^cs  temporarily  cured  by  the 
effect  of  a  loud  shout  in  the  ear. — The  Rev.  L.  D.,  aged  between  50 
and  60,  saw  me  in  the  year  1856,  but  not  on  account  of  his  deaf- 
ness, for  which  he  did  not  seek  advice  ;  I,  however,  was  able  to  glean 
the  following  interesting  details  of  his  case.  The  general  health  of 
this  gentleman  was  good,  with  the  exception  of  attacks  of  indiges- 
tion and  rheumatism,  which  caused  him  great  inconvenience.  In  a 
letter  to  me,  he  says,  "I  have  had  rheumatism  in  the  shoulder-joint, 
which  I  always  walked  off,  the  pain  becoming  much  aggravated  as  I 
got  warmer,  but  being  always  at  last  driven  out.  I  suffered  for  some 
weeks,  three  winters  ago,  from  extreme  weakness  in  both  ankle- 
joints,  so  that  I  could  scarcely  go  about  my  parish  work.  My 
friends  assured  me  that  it  was  the  beginning  of  creeping  paralysis, 
but  I  was  sure  that  the  stomach  was  the  enemy.  My  work  must  be 
done,  and  I  gradually  walked  my  legs  back  into  use."  Deafness  in 
the  right  ear  appeared  to  have  come  on  suddenly  a  few  years  before 
my  seeing  the  patient,  when  the  left  ear  was  puzzled  to  know  the 
direction  of  sounds.  "I  had  no  conception,"  he  writes,  "whence 
sounds  came,  until  by  degrees  the  left  ear  learnt  to  put  sounds  into 
their  right  places,  or  rather   to   settle  the   place   of  the   cause    of 

'  It  is  probable  that  the  crura  of  the  stapes  had  been  accidentally  disconnected  from  the 
base  in  the  act  of  dissecting  the  ear. 


THE    CAVITY    OF    THE    TYMPANUM.  309 

sound."  No  treatment  Avas  adopted,  and  tlic  patient  for  some  years 
remained  in  the  same  condition,  the  left  ear  being  useless,  or  nearly 
so,  and  the  right  remaining  tolerably  perfect.  In  the  year  1856, 
■while  this  gentleman  Avas  superintending  his  Sunday-school,  he  was 
called  upon  to  seize  a  boy  who  was  endeavoring  to  bite  his  teacher, 
when,  to  use  the  clergyman's  OAvn  words,  "  he  (the  boy)  sent  such  a 
yell  into  my  right  ear,  that  I  heard  not  only  the  yell,  but  for  some 
daA'S  I  heard  all  other  sounds  most  distinctly,  Avhen  it,  the  hearing, 
again  relapsed,  and  my  left  ear  had  again  to  learn  its  duties."  From 
the  history  and  examination  of  this  case,  I  have  no  doubt  that  the 
affection  consisted  of  rheumatic  disease  of  the  stapedio-vestibular 
articulation,  and  that  the  morbid  condition  Avas  no  other  than  that 
peculiar  expansion  of  the  base  of  the  stapes  so  frequently  adverted 
to.  The  effect  of  the  loud  scream  Avas  doubtless  to  release  the  stapes 
for  a  time,  so  as  to  alloAV  of  its  movement  by  its  muscles.  It  may 
here  be  added,  that  in  another  patient  who  was  under  my  care  for 
some  time  for  deafness  produced  by  rheumatism  of  the  ears,  an  ex- 
actly opposite  effect,  A'iz.,  complete  deafness,  was  temporarily  pro- 
duced by  a  sudden  loud  sound.  This  gentleman  was  quite  deaf  in 
one  ear,  but  Avitli  the  other  heard  a  loud  voice,  Avhen  distinctly 
spoken,  at  a  short  distance  from  him.  In  this  condition  he  Avas 
subjected  to  the  sudden  shrill  sound  of  bagpipes  played  in  the  hall 
Avhere  he  sat,  by  which  he  Avas  at  once  rendered  too  deaf  to  hear  the 
human  voice,  and  all  communications  to  him  Avere  obliged  to  be  in 
writing.  This  increased  deafness  lasted  for  several  days,  and  then 
the  ear  recovered  the  hearing  power  it  possessed  previous  to  the  ac- 
cident. There  appears  to  be  great  probability  that  in  the  latter 
case  the  cause  of  the  increased  deafness  was,  that  the  stapes  were 
driven  inwards  and  held  tight  by  the  fenestra  ovalis,  and  that  the 
return  of  the  hearing  poAvcr  Avas  due  to  the  release  of  the  stapes. 


(d.)   DISCONNECTION    OF   THE   INCUS    AND    STAPES. 

An  affection  of  the  ear  directly  opposite  to  rigidity  of  the  chain 
of  bones  sometimes  takes  place,  and  this  consists  in  the  disconnec- 
tion of  the  incus  and  stapes.  I  will  preface  my  account  of  this 
affection  by  making  some  physiological  observations  bearing  on  the 
subject. 

Physiological  Observations. — The  opinion  usually  entertained  is, 


310  THE    DISEASES    OF    THE    EAR. 

that  two  channels  are  requisite  for  the  transmission  of  sonorous  un- 
duhitions  to  the  hib^'rinth  from  the  membrana  tympani;  one  channel 
being  the  air  in  the  tympanic  cavity,  which  conducts  the  undulations 
to  the  membrane  of  the  fenestra  rotunda  and  the  cochlea  ;  the  other 
channel  being  the  chain  of  ossicles,  which  conducts  the  undulations 
to  the  vestibule. 

Tliat  this  opinion  is  not  universally  received  is  apparent  from  the 
following  quotation  from  an  authority  highly  deserving  of  attention, 
Mr.  Wharton  Jones.  He  says  : — "  Some  physiologists  assert  that 
the  sonorous  undulations  are  communicated  from  tlie  membrana 
tympani  to  the  ossicles,  and  through  them  conducted  to  the  vestibular 
fenestra ;  others  suppose  the  undulations  to  be  propagated  merely 
through  the  air  in  the  cavity  of  the  tympanum,  to  the  membrane  of 
the  fenestra  rotunda ;  the  ossicles  and  their  muscles  serving  the 
purpose  of  regulating  the  tension  of  the  membrana  tympani,  the 
membrane  of  the  vestibular  fenestra,  together  with  the  membranous 
labyrinth.  A  combination  of  the  two  views  is  most  generally  re- 
ceived. However  well  founded  the  view  may  be  that  sound  is  pro- 
pagated through  the  chain  of  small  bones,  the  circumstance  that 
some  degree  of  hearing  may  persist  along  with  loss  partial  or  com- 
plete of  the  membrana  tympani,  and  of  the  malleus  and  incus,  is  a 
conclusive  proof  that  sound  may  be  conveyed  through  the  fenestra 
to  the  labyrinth,  by  the  vibrations  of  the  air  in  the  tympanum  alone. 
It  would  appear  also,  that  the  integrity  of  one  fenestra  may  suflSce 
for  the  exercise  of  hearing."^ 

Mr.  Brooke,  Avhosc  views  on  questions  of  experimental  science  are 
worth}'  of  the 'fullest  consideration,  has  published  his  reasons  for 
believing  that  it  is  not  possible  for  the  sonorous  undulations  to  be 
conducted  to  the  labyrinth  by  the  chain  of  bones. 

He  says  :  "  The  transmission  of  sound  cannot  take  place  through 
the  ossicula,  as  it  was  formerly  supposed,  inasmuch  as  the  plane  in 
which  the  crura  of  the  stapes  lie,  is  exactly  perpendicular  to  the 
plane  passing  through  the  manubrium  of  the  malleus  and  long  leg 
of  the  incus  ;  and  consequently,  the  vibrations  passing  througli  them 
Avould  be  almost  entirely  intercepted  by  the  stapes.  And,  moreover, 
it  appears  essential  that  the  transmission  of  vibrations  through  the 
chain  of  ossicula  should  be  prevented  ;  for  as  the  velocity  with  Avhich 
sound  is  transmitted  through  solids,  such  as  bone,  so  very  far  cx- 

'  Cyclopaedia  of  Surgery.     Article,  "Diseases  of  Ear  and  Hearing,"  p.  23. 


THE     CAVITY     OF    THE    TYMPANUM.  311 

ceeds  the  velocity  in  air,  if  the  same  undulations  reach  the  labyrinth 
through  this  channel,  and  through  the  channel  previously  described 
(the  air  in  the  tympanum),  they  would  reach  in  different  times,  and 
constant  interference  ^vould  be  produced."^ 

Although  Mr.  Brooke  has  thus  confidently  expressed  his  opinion 
that  "  the  transmission  of  sound  cannot  take  place  through  the 
ossicula,"  his  statement,  unsupported  by  experiments,  and  obser- 
vations, does  not  seem  to  have  induced  'writers  on  the  physiology  of 
the  ear  to  adopt  his  conclusions.  Thus  Dr.  Carpenter,  in  the  latest 
edition  of  bis  Ilvmian  Physiology,  having  referred  to  Mr.  Brooke's 
paper,  says : — "  From  what  has  been  stated,  it  is  evident  that 
sonorous  undulations  in  the  air  will  be  propagated  to  the  fluid  con- 
tained in  the  labyrinth  through  the  tympanum,  the  chain  of  bones^ 
and  the  membrane  of  the  fenestra  oralis  to  which  the  stapes  is 
attached  without  any  loss,  but  rather  an  increase  of  intensity."^ 

Indeed,  with  a  consciousness  of  the  wonderful  accuracy  of  M. 
Savart's  experiments  in  acoustics,  it  appears  impossible,  without  fur- 
ther experiment,  to  disbelieve  the  assertion  he  made  in  the  following 
quotation  from  his  Avritings : — "  Les  vibrations  do  la  membrane 
se  communiquent  sans  alteration  au  labyrinthe  par  le  moyen  des 
osselets,  comme  les  vibrations  de  la  table  superieure  d'un  instru- 
ment communiquent  a  la  table  inferieure  par  le  moyen  de  I'ame."* 

But  supposing  with  Savart,  that  under  ordinary  circumstances 
sonorous  undulations  are  conducted  to  the  labyrinth  by  the  chain  of 
ossicles,  is  it  also  possible,  under  certain  conditions,  for  the  function 
of  hearing  to  be  carried  on  without  the  aid  of  these  bones  ?  Mr. 
Wharton  Jones  has  answered  this  question  in  the  affirmative,  as  he 
says,  that  "the  integrity  of  one  fenestra  may  suffice  for  the  exer- 
cise of  hearing;"  and  Sir  J.  Ilerschel  inclines  to  the  same  opinion. 
lie  says :  "  These  bones  form  a  kind  of  chain,  and  no  doubt  vibra- 
tions excited  in  the  tympanum  by  vibrating  air,  as  in  the  experi- 
ments above  detailed,  are  somehow  or  other  propagated  forward 
through  these  ;  but  they  are  so  far  from  being  essential  to  hearing, 
that  when  the  tympanum  is  destroyed,  and  the  chain  in  consequence 
hangs  loose,  deafness  does  not  follow."^ 

'  Report  of  a  Lecture  delivered  at  the  Roj-al  Institution;  Lancet,  1843,  p.  380. 
-  Page  733. 

'  Recherches  sur  les  Usages  de  la   Membrane   du    Tympan,   et   de   1" Oreille   externe. 
Journal  de  Phj-siologie.     Par  F.  Majendie.     Tome  iv,  p.  219. 
*  Encyelopnedia  Metropolitana.     Article,  "Pound,"  p.  810. 


312  THE    DISEASES      OF    THE    EAR. 

My  object  at  present  is  to  attempt  to  ascertain, — 

FirstJij,  whether  sonorous  undulations  from  the  external  meatus 
can  reach  the  labyrinth  -without  the  agency  of  the  ossicles ;  and, 

Secondly,  Avhether  the  chain  of  ossicles  can  conduct  sonorous  un- 
dulations to  the  labyrinth. 

Firstly.  Can  sonorous  undulations  reach  the  labyrinth  from  the 
external  meatus  without  the  agency  of  the  ossicles. - 

There  can,  I  think,  be  no  doubt  but  that  the  malleus  and  incus, 
and  even  the  crura  of  the  stapes,  can  be  removed  without  the  pro- 
duction of  any  very  serious  detriment  to  the  hearing,  but  there  is 
no  ■vvell-authenticated  case  in  which  the  base  of  the  stapes  has  been 
removed  in  ■svhich  total  deafness  did  not  ensue,  but  this  deafness 
must  doubtless  be  attributed  to  the  removal  of  the  fluid  of  the  laby- 
rinth at  the  time  the  stapes  was  withdrawn. 

But  what  is  the  effect  of  a  fixed  condition  of  the  base  of  the 
stapes  ?  Now  it  happens  that  bony  anchylosis  of  the  base  of  the 
stapes  to  the  margin  of  the  fenestra  ovalis  is  by  no  means  a  rare 
morbid  condition,  and  I  have  had  several  opportunities  of  seeing 
patients  with  this  affection  during  life,  watching  their  symptoms, 
and  subsequently  dissecting  the  organ.  The  result  of  my  observa- 
tions is  to  demonstrate  that  simple  bony  coalescence  of  the  base  of 
the  stapes  to  the  wall  of  the  vestibule -is  productive  of  so  higli  a 
degree  of  deafness,  that  the  sonorous  undulations  could  reach  the 
nerve  only  by  passing  through  the  walls  of  the  cranium  ;  and  this 
statement  accords  with  that  of  Dr.  Pappenheim,  who  found  merely 
"  some  degree  of  hearing"  in  a  similar  case.  It  may  possibly  be 
argued  that  the  deafness  occurring  in  cases  of  anchylosis  of  the 
stapes  to  the  fenestra  ovalis,  may  be  accounted  for  by  the  fixed  con- 
dition of  the  memhrana  fenestrce  rotundoi  which  necessarily  results, 
but  I  think  it  is  palpable  that  the  mere  incapacity  of  this  membrane 
to  alter  its  state  of  tension  would  not  be  suflficient  to  account  for 
the  high  degree  of  deafness  to  sounds  (acute  equally  with  the  bass) 
which  characterized  the  whole  of  the  cases  that  have  fallen  under 
my  observation.  It  may  however  be  asked,  is  it  not  possible  for 
sonorous  undulations  to  reach  the  labyrinth  without  the  aid  of  the 
stapes,  since  the  function  of  hearing  is  but  slightly  impeded  by  the 
removal  of  the  incus,  and  when  c()nsc([uently  no  vibrations  can  reach 
the  stapes,  except  througli  the  air  in  the  tympanum  ?  It  seems  in- 
deed to  have  been  assumed,  that  when  the  stapes  is  thus  detached 
from  the  incus,  it  cannot  receive  vibrations  from  the  air  externally 


THE     CAVITY    OF    THE    TYMPANUM.  313 

and  conduct  them  to  the  vestibule  ;  -what  grounds  there  exist  for  this 
conclusion  ■will  be  seen  from  the  following  experiments. 

That  solid  bodies  are  capable  of  being  thrown  into  a  state  of  vibra- 
tion by  the  agency  of  sonorous  vibrations  existing  in,  and  commu- 
nicated by,  the  air,  is  a  fact  too  Avell  known  to  require  demonstra- 
tion ;  but  the  following  experiments  show  how  far  the  solid  stapes, 
when  isolated  from  the  incus,  may  possibly  receive  vibrations  from 
the  air  and  conduct  them  to  the  labyrinth. 

Experiment. — The  ears  having  been  closed,  a  piece  of  Avood,  five 
inches  long  and  half  an  inch  in  diameter,  was  held  between  the  teeth, 
and  a  vibrating  tuning-fork,  C,  having  been  brought  within  the 
eighth  of  an  inch  of  its  free  extremity,  Avas  distinctly  heard,  and  it 
continued  to  be  heard  for  betAveen  five  and  six  seconds. 

ExpeMment. — One  end  of  the  piece  of  Avood  used  in  the  previous 
experiment  being  pressed  gently  against  the  outer  surface  of  the 
tragus,  so  as  just  to  close  the  meatus,  a  A'ibrating  tuning-fork,  C, 
placed  within  a  quarter  of  an  inch  from  the  free  extremity,  was 
heard  very  distinctly  at  first,  and  it  did  not  cease  to  be  heard  for 
fifteen  seconds. 

Experiment. — Three  portions  of  wood,  having  the  same  length 
and  thickness  as  those  used  in  the  above  experiments,  were  glued 
together  so  as  to  form  a  triangle  liaA'ing  somewhat  the  shape  of  the 
stapes.  The  base  of  this  triangle  being  placed  against  the  outer 
surface  of  the  tragus  so  as  to  close  the  meatus,  the  tuning-fork,  C, 
vibrating  Avithin  a  (quarter  of  an  inch  from  the  free  apex,  Avas  heard 
for  twelve  seconds. 

From  the  aboA'e  c^bservations  and  experiments,  I  think  it  may  be 
reasonably  inferred  that  the  stapes,  even  when  detached  from  the 
ossicles,  if  free  to  move  in  the  fenestra  ovalis,  will  receive  sonorous 
undulations  from  the  air  in  the  tympanic  cavity,  and  will  conduct 
them  to  the  labyrinth,"^  and  that  there  is  no  evidence  that  sonorous 
undulations  can  reach  the  labyrinth  from  the  external  meatus  ivithout 
the  agency  of  at  least  one  of  the  ossicles,  viz.,  the  stapes. 

I  shall  proceed  to  inquire,  in  the  second  place,  Avhether  the  chain 
of  ossicles  can  conduct  sonorous  undulations  to  the  labyrinth. 

In  this  second  part  of  the  inc^uiry,  I  shall  endeavor  to  determine, 

'  The  result  of  these  experiments  accords  with  the  fact  I  have  observed,  viz.,  that  an 
amount  of  hearing  so  eflScient  that  the  patient  was  not  supposed  to  be  deaf,  or  to  have 
deficiency  of  hearing  power,  has  been  found  to  coexist  with  isolation,  apparently  conge- 
nital, of  the  stapes  from  the  incus. 


314  TUE     DISEASES     OF    THE     EAR. 

a.  How  far  the  sonorous  undulations  excited  in  the  membrana 
tympani  are  intercepted  in  the  chain  of  ossicles  by  "  the  plane  in 
which  the  crura  of  the  stapes  lie,  being  exactly  perpendicular  to  the 
plane  ])assing  through  the  maiiubriuni  of  the  malleus  and  the  long 
leg  of  the  incus;"   and 

b.  To  what  extent  the  articulations  of  the  chain  of  bones  impede 
the  passage  of  these  inidulations. 

(a.)  To  what  extent  are  these  vibrations,  excited  in  the  membrana 
tympani,  arrested  by  the  variation  in  the  plane  of  the  chain  of  ossicles. 

After  M.  Savart's  conclusive  experiments,  repeated  and  verified 
by  so  many  subsequent  observers,  it  is  needless  for  me  to  point  out 
how  freely  sonorous  undulations  excited  in  the  air,  are  connnuni- 
cated  to  a  membrane  like  that  forming  the  membrana  tympani ;  nor 
how  fully  they  are  conducted  from  a  stretched  membrane,-  like  the 
membrana  tympani,  to  a  solid  attached  to  this  membrane  like  the 
malleus,  and  free  to  oscillate.  Assuming,  therefore,  that  the  vibra- 
tions reach  the  malleus,  I  will  proceed  to  examine  how  far  they  are 
conducted  through  it  and  the  other  ossicles. 

Experiment. — Three  pieces  of  wood,  each  five  inches  in  length 
and  half  an  inch  thick,  Avere  glued  together  so  as  to  represent  the 
planes  of  the  three  bones  of  the  ear  ;  while  three  other  portions  were 
glued  together  end  to  end,  forming  a  straight  rod.  A  watch  was 
placed  at  one  end  of  the  straight  rod,  while  the  other  end  was  ap- 
plied against  the  tragus  of  the  ear,  which  it  pressed  firmly  inwards 
so  as  to  close  the  meatus  completely  and  to  exclude  *;ounds  from 
entering  the  ear  by  it.  The  result  was,  that  the  watch  Avas  heard 
nearly  as  distinctly  as  when  it  was  placed  in  contact  Avith  the  ear. 
When  a  similar  experiment  Avas  performed  Avith  the  angular  piece  of 
Avood  representing  the  chain  of  bones,  the  Avatch  Avas  still  heard,  but 
less  distinctly. 

Experiment. — A  tuning-fork,  C,  being  made  to  vibrate,  Avas  placed 
in  contact  Avitli  one  extremity  of  the  angular  piece  of  wood,  the  other 
being  placed  against  the  tragus  of  the  ear ;  and  Avhen  the  straight 
portion  Avas  similarly  used,  it  Avas  found,  as  in  the  former  experi- 
ment, that  the  sound  Avas  decidedly  less  loud  Avhen  heard  through 
the  angular  than  through  the  straight  portion  ;  and  after  the  sound 
had  altogether  ceased  to  be  heard  through  the  angular  portion,  the 
same  tuning-fork  Avas  heard  for  about  three  seconds,  Avhen  the  straight 
piece  Avas  substituted. 

FindiuiT  that   there  existed  some  little  difficultv  in  excrcisino-  the 


THE     CAVITY     OF     THE     TYMPANUM.  315 

same  amount  of  pressure  on  the  tragus  of  tlie  ear  in  each  experiment, 
and  considering  that  a  variation  in  the  amount  of  pressure  might 
cause  the  air  in  the  meatus  to  assume  different  degrees  of  density,  I 
had  recourse  to  the  teeth  as  a  medium  for  the  transmission  of  the 
sound.  I  found  that  a  solid  phiced  in  contact  with  the  teeth  of  the 
lower  jaw  conducted  vibrations  with  rather  greater  facility  than  when 
in  contact  with  those  of  the  upper  jaw,  and  I  therefore  adopted  the 
plan  of  holding  the  conducting  body  between  the  teeth. 

Experiment. — A  tuning-fork,  C,  Avas  placed  at  one  extremity  of 
the  angular  piece  of  wood,  the  other  extremity  being  held  between 
the  teeth  ;  the  fork  was  at  first  heard  very  distinctly,  and  when  this 
sound  could  no  longer  be  distinguished,  the  straight  piece  was  sub- 
stituted, and  it  was  again  heard  for  the  space  of  two  seconds. 

Erperimcnt. — Instead  of  the  horizontal  portion  of  wood  repre- 
senting the  stapes,  three  portions  of  the  same  size  were  made  into  a 
triangle,  and  this  was  glued  to  the  anterior  surface  of  the  inferior 
extremity  of  the  piece  representing  the  incus  ;  the  last  experiment 
was  repeated,  with  the  substitution  of  this  apparatus  for  the  angular 
portion,  and  Avith  very  nearly  the  same  result,  viz.,  the  fork  was 
hoard  through  the  straight  piece  about  three  seconds  after  it  had 
ceased  to  be  heard  b}"  the  apparatus  representing  the  chain  of  bones. 

Experiment. — A  piece  of  iron  wire  eighteen  inches  long  and  about 
two  lines  in  diameter,  was  bent  so  as  to  represent  the  different  planes 
of  the  chain  of  ossicles  of  the  human  ear  ;  the  tuning-fork,  C,  Avas 
placed  at  one  extremity,  while  the  other  was  held  betAveen  the  teeth. 
The  sound  Avas  heard  very  distinctly  at  first,  and  when  it  ceased  to 
be  heard,  a  straight  portion  of  the  same  length  Avas  substituted, 
through  which  the  tuning-fork  Avas  heard  for  three  seconds. 

Experiments. — A  piece  of  very  thin  paper  was  gummed  over  one 
end  of  a  glass  tube  three  inches  in  diameter.  To  the  outer  surface 
of  this  paper  a  model  of  the  ossicula,  similar  to  the  one  Uh^ed  in  a 
previous  experiment,  Avas  glued.  A  vibrating  tuning-fork,  C,  being 
placed  in  the  interior  of  the  tube  and  Avithin  a  quarter  of  an  inch  of 
the  paper,  the  end  of  the  chain  representing  the  base  of  the  stapes 
was  placed  betAveen  the  teeth  ;  the  sound  Avas  heard  distinctly,  and 
it  continued  to  be  heard  for  ten  seconds.  The  sound  of  the  tuning- 
fork,  C",  Avas  heard  for  tAventy  seconds. 

Tlie  results  of  these  experiments  appear  to  indicate  that  the  passage 
of  sonorous  undulations  is  sometvhat,  but  only  slightly,  impeded  by 
the  variation  of  the  plane  in  ivhich  the  ossicles  are  placed. 


316  TUE     DISEASES    OF    THE     EAR. 

I  proceed,  secondly,  to  consider  tlie  effect  of  the  articulations 
between  the  ossicles,  upon  the  passage  of  sonorous  undulations 
through  them. 

The  articulating  surfaces  of  the  small  bones  of  the  ear  are  usually 
described  as  being  incrusted  by  cartilage,  which  is  covered  with  sy- 
novial membrane.  Professor  Kolliker,  speaking  of  these  bones, 
says,  "Their  articulations  and  ligaments  resemble  in  miniature 
those  of  other  similar  organs  in  all  respects,  even  down  to  the  carti- 
laginous layer,  consisting  of  scarcely  more  than  a  single  stratum."' 

Before  proceeding  with  the  inquiry  concerning  the  passage  of 
sonorous  undulations  through  the  chain  of  bones,  it  is  desirable  to 
consider  carefully  the  structure  of  their  articulations. 

They  may  be  considered  as  four  in  number,  viz.  : — 

1.  The  malleo-incudal. 

2.  The  inco-orbicular. 

3.  The  orbiculo-stapedial. 

4.  The  stapedio-vestibular. 


(1.)   The  malleo-incudal  articulation. 

The  convex  surftice  on  the  lower  and  posterior  part  of  the  head  of 
the  malleus  is  received  into  the  concavity  on  the  anterior  part  of 
the  body  of  the  incus  ;  when  applied  together,  as  they  are  retained 
by  their  ligaments  in  a  natural  state,  the  surfaces  of  these  two  bones 
appear  to  be  in  close  contact.  Upon  examining  the  articulating 
surfaces  of  the  malleus  and  incus  in  a  recent  specimen,  by  means  of 
a  lens  magnifying  five  or  six  diameters,  no  appearance  of  cartilage 
can  be  detected  ;  and  when  touched  with  a  fine  probe,  the  surface 
is  felt  to  be  hard,  as  if  no  membrane  were  present.  If,  however, 
these  articulating  surfaces  be  scraped  Avith  a  small  scalpel,  fine 
pieces  of  transparent  membrane  are  removed.  Examined  by  the 
microscope,  this  membrane,  in  some  parts,  is  seen  to  be  homoge- 
neous, having  no  appearance  either  of  fibres  or  cells  ;  in  other  por- 
tions, delicate  fibres  can  be  detected,  while  here  and  there  a  single 
layer  of  cartilage  cells  can  be  distinctly  recognized.  As  a  general 
rule,  more  cartilage  cells  are  to  be  found  in  the  membrane  removed 
from  the  incus  than  in  that  from  the  malleus. 

'  Manual  of  Human  Histiology.     By  Bu^k  and  Huxley.     Vol.  ii,  p.  404. 


THE    CAVITY    OF    THE    TYMPANUM.  317 


(2.)   The  inco-orhicidar  articulatio7i. 

The  orbicular  bone  is  sometimes  described  as  a  process  of  the 
incus.  Careful  examination  of  recent  specimens  shows,  however, 
that  the  orbicular  bone  is  connected  to  the  incus  l)y  firm  fibrous 
tissue. 

(3.)   TJic  orhicido-stapedial  articulation. 

The  orbicular  bone,  on  its  surface  towards  the  stapes,  presents  a 
slightly  convex  head,  which  is  received  into  the  superficial  con- 
cavity on  the  head  of  the  stapes.  This  convex  surface  of  the  orbi- 
cular bone  is  covered  by  a  membrane,  in  which  I  have  not  been 
able  to  detect  any  cartilage  cells.  The  outer  extremity  of  the 
stapes  is  covered  by  a  saucer-shaped  cushion,  soft  to  the  touch  ; 
and  upon  examination  by  the  microscope,  it  is  seen  to  be  a  disk  of 
fibro-cartilage,  being  a  representation  in  miniature  of  those  existing 
between  the  bodies  of  the  vertebriio,  the  circumference  being  com- 
posed of  fibres  arranged  concentrically  around  cartilage  cells  which 
occupy  the. central  position. 


(4.)   The  stapedio-vestibidar  articidation 

is  formed  by  the  circumference  of  the  base  of  the  stapes,  which  is 
applied  against  the  inner  surface  of  the  fenestra  ovalis ;  the  stapes, 
as  I  have  shown,  being  moved  by  muscles  to  and  fro  in  the  fenestra 
ovalis,  as  a  piston  moves  in  a  cylinder.  I  have  not  been  able  to 
detect  any  cartilage  on  the  surface  of  either  the  base  of  the  stapes 
or  of  the  fenestra  ovalis,  a  very  fine  membrane  alone  being  dis- 
cernible. 

The  articulatin<2;  surfaces  formin^r  the  several  articulations,  are 
connected  together  by  very  delicate  capsular  ligaments. 

The  next  step  of  my  inquiry  was  to  ascertain  by  experiment  how 
far  these  articulations  tend  to  impede  the  passage  of  sonorous  undu- 
lations through  the  chain  of  ossicles.  As  in  the  former  experiments, 
these  tympanic  ossicles  were  represented  by  portions  of  wood ;  while 
the  cartilage  and  synovial  membrane  Avere  represented  by  layers  of 
vulcanized  india-rubber. 


318  THE     DISEASES     OF    THE     EAR. 

Experiment. — Three  pieces  of  wood,  each  about  five  inches  long 
and  half  an  inch  in  thickness,  were  separated  from  each  other  by  a 
piece  of  vulcanized  india-rubber  about  as  thick  as  ordinary  writing- 
paper;  they  were  held  together  by  means  of  elastic  bands,  and  so  as 
to  assume  the  angular  form  possessed  by  the  chain.  The  tuning- 
fork  ])l:iced  at  the  distal  extremity  of  the  chain,  the  other  end  being 
placed  in  the  mouth,  it  was  found  that  the  sound  Avas  heard  as  dis- 
tinctly, and  for  the  same  length  of  time,  as  when  it  passed  through 
the  chain  formed  of  the  three  portions  glued  together. 

Experiment. — A  similar  result  took  place  when  two  layers  of 
india-rubber  were  placed  between  each  piece  of  wood. 

Experiment. — When  eight  layers  of  the  india-rubber  Avere  placed 
between  each  piece  of  wood,  there  Avas  still  very  little  diflference  in 
the  intensity  of  the  sound  when  it  passed  through  these,  and  Avhen 
it  passed  through  the  portions  glued  together. 

Experiment. — One,  two,  or  three  fingers  being  placed  between  the 
first  and  second  pieces  of  wood,  and  eight  la^'crs  of  india-rubber 
between  the  second  and  third,  a  very  slight  diminution  in  the  in- 
tensity and  duration  of  the  sound  was  observed  as  compared  with  its 
passage  through  the  pieces  glued  together,  it  being  requisite  that 
the  fingers  be  pressed  tolerably  firm  against  the  Avood. 

Experirnent. — If  the  back  of  the  hand  be  placed  against  the  teeth, 
and  the  end  of  the  vibrating  tuning-fork  be  pressed  against  the  palm, 
the  sound  is  heard  very  distinctly  for  several  seconds ;  and  when  it 
has  ceased  to  be  heard,  if  a  piece  of  solid  Avood  three  inches  long  be 
substituted  for  the  hand,  fjiint  vibrations  are  again  heard,  but  for 
about  four  seconds  only. 

Considering  the  extreme  tenuity  of  the  layers  of  cartilage  and 
synovial  membrane  Avhich  are  interposed  betAveen  the  ossicula  auditiis, 
and  the  very  slight  influence  in  arresting  the  passage  of  the  sonorous 
undulations  produced  by  layers  of  india-rubber,  the  inference  is  that 
the  ai-ticulations  bettveen  the  bones  forming  the  chain  in  the  human 
ear,  im2)ede  vert/  slightly,  if  at  all,  the  passage  of  vibrations  from  the 
memhrana  tjpnpani  to  the  lahgrinth. 

The  experiments  and  observations  detailed  above,  lead  to  the  fol- 
loAving  conclusions: — 

First. — Tliat  the  commonly-received  o})inion  in  favor  of  the  sono- 
rous undulations  passing  to  the  labyrinth  through  the  chain  of 
ossicles  in  the  human  ear,  is  correct. 

Second. — That  the  stapes,  Avhen  disconnected  from  the  incus,  can 


THE     CAVITY     OF     THE     TYMPANUM.  319 

conduct  sonorous  undulations  from  the  tympanic  cavity  to  the  ves- 
tibule. 

Tliinl. — So  far  as  our  present  experience  extends,  it  appears  that 
in  the  human  ear  sound  always  travels  to  the  labyrinth  through  two 
media,  viz.,  the  air  in  the  tympanic  cavity  to  the  cochlea,  and  one 
or  more  of  the  ossicles  to  the  vestibule. 

After  a  detail  of  the  above  results,  it  will  readily  be  assumed  that 
a  simple  disconnection  of  the  incus  from  the  stapes  is  not  productive 
of  any  large  amount  of  dulness  of  hearing.  In  the  course  of  my 
dissections  I  have  met  with  eight  cases  in  which  the  incus  was  dis- 
connected from  the  stapes,  and  in  no  instance  could  I  trace  deafness 
specially  to  this  cause.  Some  of  the  patients  from  whom  the  dis- 
sections were  taken  were  undoubtedly  deaf,  but  their  deafness  could 
be  assigned  to  other  causes  than  the  existence  of  the  solution  of  con- 
tinuity  in  the  chain  of  bones.  One  of  the  patients  in  whom  it 
occurred  was  not  detected  by  the  surgeon  to  be  deaf;  but  this  might 
arise  from  the  fact  that  the  lesion  existed  in  one  ear  only.  From 
some  researches  I  have  made  on  the  subject,  it  appears  probable 
that  the  cause  of  this  peculiar  lesion  is  hypertrophy  of  the  mucous 
membrane  of  the  tympanum  ;  in  cases  of  this  disease,  the  supply  of 
blood  to  the  substance  of  the  incus  being  interfered  with.  It  is  im- 
portant to  recognize  the  existence  of  this  disease,  and  to  do  all  that 
is  possible  to  avert  it  by  subduing  any  thickening  of  the  tympanic 
mucous  membrane,  but  it  remains  for  future  investigations  to  decide 
to  what  extent  this  lesion  interferes  with  the  hearing  power. 

Case  I. — A  man,  get.  19 ;  deaf  in  the  left  ear  ;  died  of  apoplexy. 
In  this  ear  the  membrana  tympani  contained  calcareous  matter. 
The  mucous  membrane  of  the  tympanum  Avas  very  thick.  The  ex- 
tremity of  both  long  and  short  process  of  the  incus  had  disappeared, 
and  the  surface  of  the  adjacent  bone  was  rough. 

Case  II. — A  man,  jct.  67.  Right  ear. — The  inferior  extremity 
of  the  long  process  of  the  incus  has  been  absorbed,  and  the  os  or- 
biculare  is  attached  to  the  stapes.  On  the  inner  surface  of  the 
head  and  long  process  of  the  incus  are  numerous  orifices  which 
lead  into  the  interior  of  the  bone,  giving  it  a  worm-eaten  appear- 
ance. 

Cuiic  III.  A  boy,  ait.  5;  died  from  scarlatina,  and  was  not  known 
to  be  deaf.  Right  ear  in  a  normal  state.  Left  ear. — The  os  orbi- 
culare  is  separated  from  the  incus,  and  is  attached  to  the  stapes ; 
the  stapes  is  fixed  to  the  fenestra  ovalis  more  firmly  than  natural. 


320  THE    DISEASES     OF    THE    EAR. 

The  tympanic  cavity  contained  mucus ;  lymph  Avas  also  effused,  and 
bands  of  adhesion  between  the  membrana  tympani  and  tlie  inner 
■wall  of  tlie  tympanum  were  in  process  of  formation.  The  Avhole  of 
the  inner  surface  of  the  long  process  of  the  incus  presented  a  worm- 
eaten  appearance,  and  its  lower  extremity  has  disappeared,  appa- 
rently from  absorption.  The  os  orbiculare  is  attached  to  the  neck 
of  the  stapes,  the  part  usuall}^  attached  to  the  incus  being  free  and 
rough,  and  projecting  somewhat  from  the  neck  of  the  stapes. 

Case  IV.  A  boy,  set.  3J  years ;  died  from  dysentery ;  he  was  not 
ascertained  to  be  deaf.  Right  ear. — The  incus  on  the  inner  surface 
of  its  long  process  presented  numerous  foramina,  and  the  orbicular 
process  was  partly  absorbed,  only  a  small  rougli  portion  of  it  re- 
maining attached  to  the  incus — the  inner  surface  of  the  extremity 
of  the  process  being  hollowed  out,  and  having  sharp  margins.  Left 
ear. — The  incus  is  in  the  same  state  as  that  of  the  right  ear,  and 
the  larger  part  of  the  orbicular  process  is  attached  to  the  stapes. 


CHAPTER   XIV. 

THE  MASTOID  CELLS. 


ANATOMICAL  OBSERVATIONS  :  O,  DISEASES  OF  THE  MASTOID  CELLS  IN  CHILDHOOD — 
CASES  OF  THE  DISEASE  ADVANCING  TO  THE  BONE  AND  THE  CEREBRUM.  b,  DISEASES 
OF  THE  MASTOID  CELLS  IN  THE  ADULT — ACUTE  INFLAMMATION  OF  THE  MUCOUS  MEM- 
BRANE— CHRONIC  INFLAMMATION  OP  THE  MUCOUS  MEMBRANE — PURULENT  INFECTION 
— SYMPTOMS  OF  REMITTENT  FEVER — CARIES  OF  THE  LATERAL  SULCUS — ABSCESS  IN 
THE  CEREBELLUM.  C,  NECROSIS  OF  THE  MASTOID  PROCESS — PARALYSIS  OP  THE  POR- 
TIO  DURA  NERVE — TREATMENT — OPINION  RESPECTING  LIFE-INSURANCE  IN  CASES  OP 
DISCHARGE    FROM    THE    EAR. 


As  regards  their  functions,  the  mastoid  cells  may  be  considered 
merely  in  the  light  of  an  appendage  to  the  tympanic  cavity  ;  but 
their  peculiar  conformation  and  intimate  relations  Avith  the  lateral 
sinus  render  a  special  study  of  their  diseases  necessary,  previous  to 
entering  on  which  it  is,  however,  important  thoroughly  to  under- 
stand their  anatomical  relations. 

Anatomical  Observations. — Like  the  mastoid  process,  the  mastoid 
cells  vary  much  in  size  in  different  individuals.  In  some  persons 
they  occupy  the  whole  of  the  interior  of  the  bone  behind  the  meatus 
externus  for  the  distance  of  an  inch  and  a  half ;  their  vertical  dia- 
meter is  two  inches,  and  they  extend  inwards  as  far  as  the  fossa 
jugularis;  in  other  cases  the  mastoid  process  is  almost  solid,  and  the 
cells  communicating  with  it  are  small  and  few  in  number.  The  mas- 
toid cells  may  be  considered  as  consisting  of  two  portions :  one  con- 
tained in  the  mastoid  process,  where  the  cells  have  more  or  less  of  a 
vertical  arrangement,  the  other  situated  between  the  mastoid  process 
and  the  tympanic  cavity  :  this  latter  portion  is  generally  horizontal 
and  frequently  presents  a  concavity  at  its  floor,  in  which  mucus  or 
other  secretions  are  apt  to  lodge.  On  the  inner  surface  of  the  mas- 
toid process  is  the  sulcus  lateralis,  which  is  occupied  by  the  lateral 
sinus.  Numerous  orifices  exist  in  this  sulcus  for  the  passage  of 
veins  from  the  mastoid  cells  to  the  lateral  sinus,  which  is  generally 

21 


322  THE     DISEASES     OF     THE     EAR. 

the  part  first  aifected  in  disease  of  the  mastoid  cells  occurring  in 
the  adult.  These  cells  are  bounded  anteriorly  by  part  of  the  poste- 
rior wall  of  the  meatus.  At  birth  and  during  early  life,  the  mastoid 
process  is  in  a  rudimentary  state,  and  the  only  representative  of  the 
mastoid  cells  is  the  horizontal  portion  -which  is  adjacent  to  the  tym- 
panic cavity  ;  the  extension  of  which  backwards  and  downwards,  in 
later  periods,  forms  the  cavity  of  the  mastoid  process.  It  .is  essen- 
tial that  the  relations  of  this  horizontal  portion  of  the  mastoid  cells 
in  the  earlier  periods  of  life  should  be  well  understood,  since  disease 
occurring  in  it  then  produces  entirely  difierent  results  from  those  of 
a  later  period.  If  a  vertical  section  be  made  so  as  to  pass  through 
this  horizontal  portion  in  the  temporal  bone  of  a  child  about  two 
years  of  age,  these  mastoid  cells  will  be  observed  to  be  bounded 
externally  by  a  part  of  the  S({uamous  bone,  which  is  superior  and 

Fio.  94. 


The  External  Surface  of  the  Temporal  Bone  of  a  child.  The  outer  wall  of  the  horizontal 
portion  of  the  cells  has  been  removed,  and  the  cavity  of  this  portion  of  the  cells  above 
the  Mastoid  Process  is  exposed. 

slightly  posterior  to  the  meatus  externus ;  and  it  is  this  particular 
part  which  becomes  affected  in  cases  of  disease  of  the  mastoid  cells 
in  early  life.  The  upper  Avail  of  the  horizontal  portion  of  tlie  mas- 
toid cells  is  formed  by  a  layer  of  bone,  continuous  with  that  of  the 
upper  wall  of  the  tympanum.  This  lamina  partakes  of  the  disease 
of  the  cavity,  and  thus  the  dura  mater  and  cerebellum  become  liable 
to  be  affected  when,  in  early  life,  disease  occurs  in  the  mastoid  cells. 
Before  the  second  year  this  cellular  cavity  is  comparatively  much 
larger  than  at  a  later  period. 


THE    MASTOID    CELLS. 


323 


The  diseases  of  the  mastoid  cells  in  the  child  will  be  first  described, 
and  afterwards  those  in  the  adult. 


Fig.  95. 


A  Vertical  Section  of  the  Temporal  Bone  of  a  child  through  the  horizontal  portion  of  the 
Mastoid  Cells.  It  is  seen  to  he  hounded  externally  by  the  layer  of  bone,  which  has 
been  removed  in  the  preceding  cut,  and  which  usually  becomes  carious  in  cases  of  dis- 
ease in  the  horizontal  portion  of  the  cells  in  early  life. 


{a.)    DISEASES    OF    THE    MASTOID    CELLS   IN    CHILDHOOD. 


The  most  frequent  causes  of  disease  in  the  mastoid  cells,  as  in 
the  tympanum,  at  this  period,  are  scarlet  fever,  measles,  small-pox, 
and  scrofulous  affections.  In  the  three  former  of  these  affections, 
the  mucous  membrane  is  usually  the  subject  of  chronic  catarrh, 
becomes  hypertrophied,  and  mucus  collects  in  the  cells.  In  the 
undeveloped  state  of  the  mastoid  process  in  childhood,  the  mucus 
collects  in  the  horizontal  portion,  bounded  externally,  as  already  de- 
scribed, by  the  squamous  bone,  and  above  by  the  continuation  of  the 
lamina  forming  the  upper  tympanic  wall.  Hence  it  is  evident  that 
the  portions  of  bone  liable  to  be  affected  by  disease  in  the  mastoid 
cells  of  the  child,  are  the  squamous  bone  immediately  above  and 
behind  the  external  meatus,  and  the  posterior  part  of  the  upper 
wall  of  the  tympanum.  Dissection  shows  also  that  these  two  parts 
are  in  fact  those  which  do  become  affected,  and  that  in  cases  of  dis- 
ease attacking  the  mastoid  cells  in  early  life,  the  cerebrum  is  the 


324  THE     DISEASES     OF    THE    EAR. 

part  of  the  brain  Avliich  suffers,  while,  as  we  shall  see  in  later 
periods  of  life,  the  cerebellum  becomes  affected. 

In  disease  of  this  part  the  discharge  from  the  affected  ear  often 
dates  from  birth,  and  is  generally  at  first  unaccompanied  by  any 
pain ;  so  that  too  often  (especially  among  working  people)  no  notice 
whatever  is  taken  of  it.  In  its  earlier  stages  the  discharge  appears 
to  be  purely  sympathetic,  and,  as  in  many  other  cases  of  irritation 
of  the  tympanic  mucous  membrane,  it  proceeds  from  the  meatus  and 
the  outer  surface  of  the  membrana  tympani.  As  the  disease  pro- 
gresses, the  tympanum  becomes  filled  by  mucus  or  scrofulous  matter, 
and  the  membrana  tympani  yields  to  the  pressure  on  its  inner  sur- 
face; and  no  doubt  in  some  cases,  if  a  thorough  outlet  be  thus  made 
for  the  discharge  from  the  mastoid  cells,  while  the  health  of  the 
patient  at  the  same  time  improves,  no  further  mischief  accrues ;  but 
unfortunately  the  peculiar  conformation  of  this  part  of  the  mastoid 
cells  usually  prevents  the  free  escape  of  the  matter ;  part  of  it,  at 
least,  remains  lodged  in  its  concavity,  or  the  whole  is  barred  from 
exit  by  the  closure  of  the  tympanic  cavity  through  the  hypertrophy 
of  the  lining  mucous  membrane.  In  all  fatal  cases  the  discharge 
has  been  deprived  of  a  free  egress. 

One  of  the  peculiar  features  of  the  disease  is,  that  it  sometimes 
causes  death,  by  producing  general  cerebral  irritation  rather  than 
inflammation.  In  the  first  two  cases*  which  follow,  there  was  no 
appearance  of  disease  in  the  brain,  pia  mater,  or  arachnoid  ;  in  the 
third  case  these  parts  were  but  slightly  affected  in  comparison  with 
the  large  amount  of  disease  in  the  ear. 

Case  I.  Scrofulous  disease  of  the  liorizontal  portionof  the  mastoid 
cells  before  the  first  year  of  life  ;  caries  of  the  squamous  bone;  disease 
of  the  dura  mater. — J.  R.,  aged  thirteen  months,  Avas  admitted  under 
my  care  as  an  out-patient,  at  St.  Mary's  Hospital,  on  the  12tli 
February,  1852.  Although  she  had  a  good  color  and  was  not  thin, 
her  mother  stated,  tliat  since  her  birth  she  had  never  been  strong, 
and  that  she  had  been  brought  up  by  hand,  on  account  of  herself 
(the  mother)  having  an  abscess  in  one  breast.  The  history  was, 
that  at  six  ^'cars  old  a  discharge  was  observed  to  flow  from  the  right 
car,  Avhich  had  continued  to  the  present  time  with  but  short  inter- 
missions. Three  weeks  ago  an  abscess  formed  at  the  back  of  the 
car  and  discharged  into  the  meatus.     On  inspection,  the  surface  of 

'  A  somewhat  analogous  case  has  been  cited  as  having  occurred  to  Dr.  Chambers. 


THE    MASTOID     CELLS.  825 

the  meatus  was  seen  to  be  red,  and  its  substance  so  much  tumefied 
as  to  prevent  its  being  ascertained  Avhether  the  niembrana  tympani 
■was  or  was  not  present.  The  discharge  consisted  of  pus  and  mucus. 
The  abscess  behind  the  ear  communicated  with  the  meatus  by  an 
aperture  at  its  posterior  part.  The  ear  was  ordered  to  be  syringed 
with  warm  water. 

February  19th. — Symptoms  much  the  same,  but  the  discharge 
more  oifensive. 

Until  the  1st  of  April  "the  symptoms  gradually  subsided,  the  dis- 
charge diminished,  and  the  child  appeared  stronger.  On  the  2d, 
however,  the  discharge  grew  more  offensive,  and  less  in  quantity. 
On  the  8th  the  child  cried,  as  if  in  pain,  and  started  in  her  sleep. 

April  15tli. — Leeches  afforded  some  relief,  and  were  ordered  to 
be  continued. 

19th. — Has  had  shivering  fits  to-day.  From  this  date  the  head- 
symptoms  gradually  increased ;  the  respiration  became  difficult,  and 
the  child  died  in  convulsions  on  the  29th. 

Autopsy. — The  part  of  the  sterno-mastoid  muscle  attached  to  the 
mastoid  process  was  discolored.  The  membranous  meatus  was  much 
thickened,  and  of  a  dark  purple  color.  The  posterior  part  of  the 
osseous  meatus  was  carious ;  and  the  bone  continuous  with  and  above 
it,  for  a  space  the  size  of  a  sixpenny-piece,  was  also  carious  ;  this 
being  the  portion  of  bone  which  bounds  externally  the  horizontal 
mastoid  space.  The  periosteum  covering  this  carious  bone  is  thick 
and  soft  in  some  parts,  and  ulcerated  in  others.  There  is  also  in- 
ternally a  portion  of  necrosed  bone  about  one-half  the  size  of  that 
externally  ;  and  upon  a  section  the  inner  surface  is  found  to  be  part 
of  the  necrosed  portion  of  bone  which  is  seen  externally,  where  it 
covers  the  tympanic  cavity  and  extends  above  it.  The  outer  surface 
of  the  dura  mater  which  is  in  contact  with  the  dead  bone,  is  soft, 
spongy,  and  of  a  dark  color,  and  partly  filled  the  superficial  cavity 
formed  by  the  necrosed  bone :  in  immediate  contact  with  that  bone, 
however,  was  a  soft  pulpy  tissue.  The'membrana  tympani  was 
absent,  the  mucous  membrane  of  the  tympanum  ulcerated,  and  the 
ossicles  carious.  The  lungs  were  tuberculous,  the  mesenteric  glands 
large,  containing  also  scrofulous  matter. 

The  following  case  is  very  analogous  to  the  one  just  reported. 

Case  II.  Scrofulous  disease  in  the  horizontal  portion  of  the  mas- 
toid cells  in  the  frst  year  of  life  ;  caries  of  squamous  hone  and  dis- 
ease of  dura  mater. — E.  B.,  aged  sixteen  months,  subject  to  scro- 


326 


THE     DISEASES     OF     THE     EAR. 


fulous  glands,  was  admitted  under  my  care  at  the  St.  George's  and 
St.  James's  Dispensary,  in  November,  1849.  When  seen,  there 
was  a  large  abscess  behind  the  left  ear  and  discharge  from  the 


The  External  Surface  of  the  Temporal  Bone,  showing  the  irregular-shaped  carious  portion 
of  bone  above  the  Meatus. 


meatus.  The  merabrana  tympani  was  absent,  the  mucous  mem- 
brane of  the  tympanum  thick  and  red.  At  the  bottom  of  an 
abscess  behind  the  ear,  dead  bone  could  be  felt.  Her  mother  stated 
that  there  was  discharge  from  the  right  ear  at  the  age  of  three 
months,  which  lasted  six  or  seven  weeks,  and  then  disappeared. 
"When  five  months  old,  discharge  took  place  from  the  left  ear,  and 
after  continuing  for  a  month,  a  swelling  appeared  at  the  back  of  the 
ear,  which  was  opened  and  continued  discharging,  as  well  as  the 
meatus,  to  the  time  I  saw  the  patient.  Soon  after  seeing  her,  the 
symptoms  of  cerebral  irritation,  which  had  shown  themselves  at 
times  in  the  form  of  great  pain  in  the  left  side  of  the  head,  rapidly 
increased ;  and  in  face  of  all  the  remedial  measures  employed,  death 
ensued  in  a  few  days. 

Autopsy. — On  slitting  open  the  abscess  at  the  back  of  the  ear, 
the  bone  above  and  posterior  to  the  meatus  externus,  over  the  space 
of  a  sixpence,  was  denuded,  and  was  rough,  black,  and  soft :  the 
external  table  had  been  removed.  On  making  a  vertical  section  of 
the  bone  through  the  horizontal  portion  of  the  cells,  thg  walls  of 
the  latter  were  observed  in  a  state  of  disease,  and  the  cavity  con- 
tained purulent  matter.     The  outer  wall  of  this  portion  of  the  cells 


THE    MASTOID     CELLS. 


327 


was  carious  throughout.  The  membranus  meatus  was  softer  than 
natural.  The  membrana  tympani  liad  been  entirely  removed  by 
ulceration,  as  also  parts  of  the  tympanic  mucous  membrane ;  the 


Fig.  97. 


A  Vertical  Section  of  the  Diseased  Bone.  The  walls  of  the  horizontal  mastoid  cavity  are 
diseased  ;  the  upper  wall  forming  part  of  the  cerebral  cavity,  and  continuous  with  the 
external  wall,  is  carious  ;  the  entire  substance  of  the  external  wall  is  dead. 

small  portions  remaining  being  thick,  soft,  and  of  a  livid  color.  The 
long  process  of  the  malleus  had  disappeared,  and  the  remnant  was 
partially  disconnected  from  the  incus,  as  was  the  incus  from  the 
stapes.  The  inner  surface  of  the  carious  bone  is  of  a  dark  color, 
and  is  itself  carious,  presenting  numerous  small  depressions.  The 
thick,  soft,  and  red  dura  mater  was  separated  from  the  carious  bone 
by  a  transparent  fluid.  On  examining  the  right  ear,  the  same  dis- 
ease appeared,  but  in  an  incipient  state ;  the  meatus  was  soft  and 
red ;  the  membrana  tympani  thick,  white,  and  concave ;  the  mucous 
membrane  lining  the  tympanum  and  mastoid  cells,  was  thick  and 
red ;  and  there  Avas  a  collection  of  mucus.  Another  case,  which 
occurred  under  the  care  of  Mr.  II.  J.  Johnson,  when  assistant-sur- 
geon to  St.  George's  Hospital,  is  as  nearly  as  possible  a  counterpart 
of  the  one  just  cited  ;  and  the  specimen  for  which  I  am  indebted  to 
that  gentleman,  is  almost  a  fac-similc  of  the  preceding  one. 

Disease  sometimes  extends  uj^Avards  and  outwards,  and  destroys 
nearly  the  whole  of  the  squamous  portion.  A  case  of  this  kind  Avas 
brought  under  my  notice  by  Mr.  "Willing,  of  Ilampstead.  The  fol- 
lowing are  the  particulars  furnished  by  him. 


328  THE    DISEASES     OF    THE    EAR. 

Case  III.  Scrofulous  disease  in  the  horizontal j^ortion  of  the  mas- 
toid cells  before  the  first  year;  destruction  of  a  large' part  of  the 
squamous  hone  by  caries;  disease  of  the  dura  mater ;  a  small  abscess 
in  the  cerebrum, — M.  A.  W.,  aged  11  months,  the  youngest  of  three 
children  ;  the  other  tAvo  were  healthy.  The  parents  are  in  bad 
circumstances  ;  the  mother  very  emaciated,  having  during  her  preg- 
nancy had  very  insufficient  food,  owing  to  her  husband,  a  brick- 
layer's laborer,  being  out  of  work  for  a  long  time.  The  child  was 
first  seen  by  Mr.  Willing  in  June,  1850,  and  was  then  three  months 
old,  small  and  much  atrophied.  The  mother  said  it  was  small  Avhen 
born  ;  and  as  she  had  no  milk,  she  endeavored  to  bring  it  up  by 
hand.  There  had  been,  she  added,  a  discharge  from  the  right  ear 
since  birth.  On  examination,  a  redness  and  tumefaction  both  of 
the  meatus  and  ear  were  observed,  with  evident  tenderness  on  pres- 
sure of  the  mastoid  process,  and  the  cervical  glands  were  enlarged. 
The  child  suffered  under  diarrhoea,  and  was  extremely  weak.  Cod- 
liver  oil  was  administered,  and  emollients  applied  to  the  ear,  which 
was  syringed  daily  with  warm  water.  Under  this  treatment,  the 
child  somewhat  improved  until  October,  when  paralysis  occurred  on 
the  left  side  of  the  face.  The  discharge  grew  more  abundant,  the 
soft  parts  round  the  ear  became  sloughy,  and  the  mastoid  process 
offered  no  resistance  to  pressure.  These  symptoms  lasted  till  the 
death  of  the  child  in  February. 

Autopsy,,  thirty-tivo  hours  after  death. — The  body  was  so  much 
emaciated  as  to  be  scarcely  larger  than  at  birth.  The  dura  mater 
was  very  thin,  and  the  surface  of  the  brain  greatly  congested,  with 
patches  of  dark-colored  blood  scattered  over  its  hemispheres,  espe- 
cially on  the  right  side,  where,  in  one  or  two  places,  they  extended 
to  the  depth  of  three  or  four  lines  into  the  substance  of  the  brain. 
The  cerebral  veins  were  distended  by  coagula.  At  the  surface  of 
the  posterior  part  of  the  middle  lobe,  on  the  right  side,  was  a  small 
abscess,  the  size  of  a  pea.  The  ventricles  contained  about  three 
ounces  of  thick,  turbid  serum.  The  middle  cerebral  artepes  Avere 
distended  by  firm  fibrin,  and  there  were  about  four  ounces  of  fluid 
at  the  base  of  the  brain.  The  dura  mater  covering  the  petrous 
portion  of  the  right  temporal  bone  was  separated  from  it  by  pus, 
and  very  much  thickened. 

On  examining  the  temporal  bone,  which  Mr.  Willing  presented  to 
me,  I  found  that  the  part  of  the  squamous  portion  between  the  root 
of  the  zygomatic  process  and  the  mastoid  process  had  been  entirely 


THE    MASTOID     CELLS. 


329 


destroyed  ;  and  that  the  larger  part  of  the  mastoid  process  had 
also  disappeared,  causing  an  aperture  an  inch  in  length,  and  three- 
quarters  of  an  inch  in  depth.  The  petrous  bone  was  detached,  and 
both  its  superior  and  posterior  sm-faces  were  carious.  The  small 
remaining  portion  of  the  mastoid  cells  contained  scrofulous  matter. 

In  other  cases  the  diseases  may  advance  to  a  very  considerable 
extent,  and  then,  supposing  the  health  to  improve,  reparative  efforts 
may  be  made.  A  highly  interesting  case  of  this  kind  was  brought . 
under  my  notice  through  the  kindness  of  Mr.  French,  to  whom  I 
am  indebted  for  the  opportunity  of  making  a  careful  dissection  of 
the  ear.  The  case  derives  additional  interest  from  the  fact  tliat  it 
was  the  subject  of  judicial  proceedings,  the  exciting  cause  of  the 
fatal  symptoms  being  a  blow  on  the  head. 

Case  IV.  Catarrh  of  the  mucous  membrane  of  the  horizontal  por- 
tion of  the  mastoid  cells  in  childhood;  caries  of  the  hone;  imrtial 
reparation  hy  deposit  of  neio  hone.  Death  folloiving  a  hloiv  on  the 
head;  abscess  in  cerebrum. — E.  C,  aged  12,  previously  in  good 
health,  Avas  seen  on  the  3d  of  July,  1850,  on  account  of  violent  pain 
in  the  head,  chiefly  in  the  left  temporal  region,  accompanied  by  severe 
febrile  symptoms.  The  day  before  she  had  received  a  violent  blow, 
on  the  head,  during  a  scuffle ;  she  was  thrown  down,  her  head  struck 
against  the  door,  and  subsequently  against  the  wall :  a  similar,  but 
less  severe  assault,  was  repeated  a  few  minutes  afterwards.  On 
examination,  there  was  a  fulness  of  outline,  and  a  puffiness  of  the 
temporal  muscle.  The  symptoms  of  cerebral  irritation  and  fever 
rapidly  increased  ;  a  large  abscess  formed  beneath  the  temporal 
muscle  ;  discharge  issued  from  the  ear  ;  coma  ensued  ;  and  death 
occurred  twenty-two  days  after  the  injury.  It  could  not  be  ascer- 
tained whether  there  was  a  history  of  discharge  from  the  ear  in 
earlier  childhood. 

Autopsy. — The  pericranium  was  found  separated  from  the  squa- 
mous bone  by  purulent  matter ;  the  dura  mater  lining  the  squamous 
bone,  and  covering  the  upper  wall  of  the  tympanum,  was  thicker 
than  natural,  and  but  slightly  adherent  to  the  bone ;  the  arachnoid 
and  a  portion  of  cerebral  matter  Avere  attached  to  this  part  of  the 
dura  mater.  In  the  cavity  of  the  middle  cerebral  lobe  was  an 
abscess  containing  four  ounces  of  pus.  The  petrous  bone  was  dis- 
eased. The  membranous  meatus  was  thicker  than  natural,  and  its 
free  surface  was  smooth,  presenting  no  signs  of  ulceration.  The 
superior  and  posterior  walls  of  the  osseous  meatus  were  rough,  and 


330  THE    DISEASES     OF    THE    EAR. 

this  roughness  was  produced  by  a  deposit  of  new  bone,  which  was 
also  found  to  extend  on  the  outer  surface  of  the  squamous  bone, 
above  the  meatus,  for  a  space  measuring  half  an  inch  in  its  vertical, 
and  an  inch  in  its  antero-posterior  diameter.  The  posterior  tAVO- 
thirds  of  the  mombrana  tympani  were  absent ;  the  mucous  membrane 
of  the  tympanum  was  liealthy  ;  but  in  the  passage  to  the  mastoid 
cells  there  was  a  collection  of  pus  and  scrofulous  matter,  which  had 
■  not  been  freely  discharged  on  account  of  the  small  size  of  the  aper- 
ture leading  into  the  tympanum,  contracted  as  it  was  by  the  thick 
mucous  membrane.  The  upper  wall  of  the  tympanum  was  in  a  dis- 
eased state;  the  surface  next  to  the  dura  mater  being  composed  of 
a  very  fine  scale  of  dead  bone,  about  six  inches  long  by  four  broad, 
which  was  perforated  by  small  orifices,  and  eaten  away  posteriorly 
in  parts.  Beneath  this  dead  bone  Avas  a  layer  of  new  bone,  which 
formed  the  upper  wall  of  the  tympanum,  and  was  continued  upwards 
and  outwards  on  the  inner  surfi\ce  of  the  squamous  bone  to  its  upper 
margin.  The  old  bone  underneath  and  adjacent  to  the  new  bone 
was  worm-eaten,  and  had  been  the  seat  of  the  disease ;  it  was  about 
half  an  inch  in  breadth. 

•  There  can  be  no  doubt,  from  tlie  examination  of  the  specimen, 
that  disease  in  the  horizontal  portion  of  the  mastoid  cells  had  com- 
menced in  early  childhood ;  that,  as  in  the  cases  previously  cited, 
the  squamous  bone  became  diseased,  the  dura  mater  and  the  cere- 
brum being  also  afiected,  but  not  to  such  a  degree  as  to  endanger 
life.  It  would  further  appear,  that  as  the  bone  was  developed,  new 
bone  was  deposited  on  each  side  of  the  diseased  squamous  bone,  and 
extended  into  the  meatus,  which,  it  will  be  remembered,  forms  in  the 
first  few  years  of  life  part  of  the  squamous  bone  ;  and  it  is  possible 
that,  in  spite  of  the  disease  of  the  brain  and  dura  mater,  the  patient 
might  have  lived  many  years,  if  no  very  active  exciting  cause  had 
been  brouglit  into  operation.  At  the  same  time,  it  is  most  probable 
that  the  blow  on  the  head  would  not  have  caused  death  had  there 
not  been  pre-existing  disease  ;  and  in  this  view  the  Grand  Jury 
concurred. 

The  peculiar  anatomical  relations  of  the  mastoid  cells  in  childhood 
have  now  been  pointed  out :  it  has  been  shown,  that  in  the  first  year 
of  life  the  mastoid  process  is  not  developed,  and  consists  merely  of 
the  horizontal  portion,  wliich  is  intimately  connected  with  the  cere- 
bral cavity,  to  whicli,  in  cliihlhood,  disease  is  usually  propagated 
ratlicr  than  to  the  cavity  of  the  cerebellum.     Those  cases  of  disease 


THE     MASTOID     CELLS.  331 

in  early  life  which  have  been  hitherto  described,  must  be,  therefore, 
Considered  as  exceptions  to  the  rule  previously  laid  down  by  nie, — 
that  affections  of  the  mastoid  cells  produce  disease  in  the  cerebellum. 


{h.)    DISEASES    OF    THE    MASTOID    CELLS    IN    THE    ADULT. 

Subsequent  to  the  second  or  third  year  of  life,  when  the  mastoid 
process  is  somewhat  developed,  it  will  be  found  that  the  layer  of 
bone  bounding  the  horizontal  portion  externally,  attains  to  a  thick- 
ness of  three  or  four  lines,  and  becomes  extremely  dense.  Hence, 
after  the  first  or  second  year  of  life,  disease  is  scarcely  ever  observed 
to  extend  from  the  horizontal  portion  to  the  outer  surface  of  the 
squamous  bone  ;  but  as  the  cells  are  developed  posteriorly,  and  con- 
tract intimate  relations  with  the  lateral  sinus  and  the  cerebellum,  it 
is  to  these  two  parts  that  disease  is  communicated. 

Cases  of  disease  in  the  mastoid  cells  may  be  divided  into  acute 
and  chronic. 

I.  Acute  inflammation  of  the  mucous  membrane  lining  the  mastoid 
cells. — This  affection  is  somewhat  rare,  and  when  it  does  occur,  is 
usually  subdued  before  it  progresses  to  the  bone  or  dura  mater. 

Cases,  however,  are  occasionally  met  with  in  which  acute  inflam- 
mation of  the  mucous  membrane  lining  the  mastoid  cells  ends  in 
suppuration,  the  lateral  sinus  becomes  inflamed,  and  abscesses  occur 
in  the  brain.  The  following  is  a  case  of  the  kind  which  occurred  to 
Dr.  Brinton,  at  the  Royal  Free  Hospital,  to  whom  I  am  indebted 
for  the  notes  of  the  case,  and  for  the  opportunity  of  making  the 
dissection. 

Case  I.  Acute  inflammation  of  the  mucous  membrane  lining  the 
mastoid  cells  ;  suppuration  ;  disease  of  the  lateral  sinus  ;  abscess  in 
the  cerebellum. — A  girl,  aged  21,  was  admitted  into  the  hospital, 
three  weeks  subsequent  to  an  attack  of  scarlet  fever.  The  history 
was,  that  since  the  fever,  she  has  had  a  constant  and  abundant  dis- 
charge from  the  left  ear.  On  admission,  this  discharge  was  observed 
to  be  copious  ;  she  was  drowsy,  and  at  times  almost  comatose,  with 
a  rapid  feeble  pulse,  a  cold  body  and  limbs,  and  a  hot  face  and  head. 
In  spite  of  all  the  remedies  employed,  the  coma  gradually  grew  more 
intense,  and  she  died  ten  days  after  her  admission. 

Autopsy. — An  abscess  Avas  found  in  the  left  lobe  of  the  cerebellum, 
of  the  size  of  a  walnut.     It  extended  to  the  surface,  and  thus  came 


332  THE     DISEASES     OF    THE    EAR. 

in  contact  with  a  large  qnantitv  of  pus,  bounded  by  the  diseased  and 
distended  -walls  of  the  lateral  sinus,  Avhich  latter  contained  pus  and 
blood.  There  was  an  opening  through  the  membrana  tympani  of  a 
regular  shape,  and  of  a  size  one-third  the  whole  dianfeter  of  the  mem- 
brane. The  upper  wall  of  the  tympanum  was  healthy,  and  not  eyen 
discolored.  The  portion  of  the  mastoid  cells  posterior  to  the  incus 
contained  some  pus  and  blood  mixed  together  ;  this  extended  down 
as  far  as  the  mastoid  process.  The  portion  of  the  lateral  sulcus, 
about  an  inch  long  by  half  an  inch  broad,  Avhich  forms  the  exterior 
boundary  of  this  part  of  the  mastoid  cells,  was  of  a  dark  leaden 
color.  The  canals  in  this  portion  of  the  bone  were  also  distended 
with  black  matter. 

It  seems  to  me,  there  can  be  no  doubt  that,  in  this  case,  the  puru- 
lent matter  from  the  mastoid  cells  was  the  cause  of  the  disease  in  the 
lateral  sinus,  for  the  bloodvessels  between  the  two  parts  were  dis- 
tended with  dark  pus  and  blood. 

II.  Chronic  injlammation  of  the  mucous  membrane  lining  the  mas- 
toid cells. — Cases  of  chronic  disease  of  the  mastoid  cells  usually  take 
their  origin  before  the  adult  period  of  life,  although  the  more  seri- 
ous symptoms  may  not  be  developed  until  after  that  period.  As 
in  disease  of  the  tjnnpanum,  the  cases  now  under  consideration 
commonly  originate  in  chronic  inflammation  of  the  mucous  mem- 
brane. Whatever  may  be  the  cause  of  this  inflammation, — whether 
scarlet  fever,  measles,  or  an  ordinary  cold, — the  result  is  the  secre- 
tion of  a  larger  quantity  of  mucus  than  is  natural,  which  in  the 
milder  forms  of  the  affection  is  afterwards  absorbed,  or  else  dis- 
charged through  the  tympanic  cavity  and  Eustachian  tube,  into  the 
cavity  of  the  fauces  ;  but  in  the  more  severe,  to  which  attention  has 
now  to  be  directed,  the  mucous  secretion  is  too  abundant  to  escape 
from  the  cells,  and  the  bone  becomes  affected. 

The  effects  of  chronic  disease  in  the  mastoid  cells  upon  the  lateral 
sinus  and  cerebellum  are  : — 

1st.  Suppuration  in  the  lateral  sinus  with  or  without  secondary 
purulent  deposits. 

2d.  Inflammation  of  the  dura  mater  and  arachnoid,  and  the  forma- 
tion of  pus  on  the  surface  of  the  cerebellum. 

3d.  Abscess  in  the  cerebellum. 

The  history  of  cases  of  chronic  disease  in  the  mastoid  cells  bears 
some  analogy,  to  that  of  those  occurring  in  the  tympanic  cavity,  al- 
though, as  a  general  rule,  there  is  more  irritation  from  the  outset  of 


THE    MASTOID     CELLS.  333 

the  aifcction,  and  consequently  attention  is  attracted  to  the  case  in 
its  early  stages  ;  and  this  is  the  reason,  as  will  be  seen  when  the 
treatment  is  spoken  of,  Avhy  the  disease  is  more  amenable  to  reme- 
dial measures  than  when  it  attacks  the  tympanum.  The  following 
may  be  taken  as  the  ordinary  history  of  a  case  of  disease  advancing 
from  the  mastoid  process  to  the  lateral  sinus  or  cerebellum.  The 
patient,  who  has  often  a  tendency  to  glandular  enlargements,  has 
suffered  when  a  child  from  pain  in  the  ear,  followed  by  discharge. 
During  childhood,  and  perhaps  up  to  adult  age,  there  have  occurred 
attacks  of  pain  and  discharge  at  intervals  of  some  months.  Between 
the  attacks  there  is  often  a  sensation  of  pain  in  the  region  of  the 
mastoid  process  and  back  of  the  head,  and  giddiness  sometimes 
comes  on.  These  symptoms  are  aggravated  by  fatigue  or  any  other 
depressing  influence.  Upon  examination,  the  surface  of  the  meatus 
is  seen  to  be  red,  and  to  be  the  source  of  the  discharge.  No  perfo- 
ration exists  in  the  membrana  tympani,  which,  however,  is  white  and 
thickened,  so  that  the  discharge  is  purely  sympathetic.  The  surgeon 
is  more  commonly  called,  however,  to  cases  where  the  symptoms 
have  become  much  more  urgent,  and  where,  indeed,  the  disease  has 
advanced  so  far  that  the  brain  or  its  membranes  have  become  so 
greatly  disorganized  as  to  defy  all  remedial  measures. 

Cases  of  disease  in  the  mastoid  cells  terminate  fatally  from  two 
different  causes. 

1st.  From  purulent  infection,  arising  from  the  introduction  of  pus 
into  the  circulation  through  the  lateral  sinus. 

2d.  From  disease  of  the  cerebellum  or  its  membranes. 

Cases  of  pwulent  infection  have  not  been  met  with-  when  the 
disease  occurs  in  the  tympanic  cavity.  On  account  of  the  proximity 
of  the  jugular  vein  to  the  lower  wall  of  the  tympanum,  it  is,  however, 
quite  possible  for  disease  to  extend  to  the  venous  system. 

Dr.  Abercrombie  published  an  interesting  case  of  purulent  infec- 
tion from  disease  of  the  ear ;  but  the  subject  has  been  more 
thoroughly  investigated  by  Dr.  Watson,  who,  although  deprived  of 
the  opportunity  of  making  post-mortem  inspections  of  the  highly 
important  cases  he  has  so  fully  described,  had  no  doubt  in  his  mind, 
and  leaves  no  doubt  in  the  minds  of  his  readers,  that  the  cause  of 
death  was  the  introduction  of  pus  into  the  system  from  the  mastoid 
cells.  Dr.  Bruce  has  since  published  some  valuable  cases  bearing 
upon  the  subject ;  Mr.  Wilde  gives  the  details  of  a  case  in  his  work 
on  the  ear ;  and  more  recently  still.  Dr.  Gull,  in  the  Guy's  Hospital 


331:  THE    DISEASES    OF    THE    EAR. 

Reports,  has  thrown  much  light  on  the  subject.  The  facts  brought 
forward  by  these  gentlemen,  coupled  with  those  which  are  now  to  be 
related  as  the  result  of  my  own  experience,  will,  I  trust,  lead  to  a 
thorough  comprehension  of  the  nature  and  progress  of  the  disease. 
Dr.  Abercrombie's  case  is  the  following  : — 

Disease  of  the  mastoid  cells  ;  deposit  in  the  lateral  sinus  ;  secon- 
dary deposit  in  the  pleura. — A  young  lady,  aged  15,  had  been  liable 
for  six  or  seven  years  to  attacks  of  pain  in  the  right  ear,  followed 
by  discharge  of  matter ;  but  she  had  been  free  from  any  of  these 
attacks  for  some  time  previous  to  the  abscess  which  forms  the  sub- 
ject of  the  following  history.  On  the  25th  April,  1822,  she  com- 
plained of  cold  shivering  through  the  day,  and  in  the  evening  had 
headache  with  pain  in  the  right  ear,  symptoms  which  continued  on 
the  following  day.  On  the  28th  she  was  seen  by  Mr.  Brown,  who 
found  her  with  quick  pulse  and  foul  tongue,  severe  pain  in  the  ear, 
and  slight  headache.  On  the  29tli  some  discharge  took  place  from 
the  ear,  but  without  relieving  the  pain  which  continued  with  violence 
until  the  next  day.  On  the  1st  of  May  the  pain  had  somewhat 
abated  in  the  ear,  but  had  extended  over  the  right  side  of  the  head; 
pulse  frequent.  General  and  local  bloodletting  were  employed 
with  partial  relief.  I  saw  her  on  the  3d ;  the  headache  Avas  then 
rather  abated  ;  the  pulse  was  frequent  and  weak  ;  she  had  a  pale, 
unhealthy  aspect,  and  a  look  of  oppression  bordering  upon  coma. 
The  pain  Avas  chiefly  referred  to  the  parts  above  and  behind  the 
right  ear,  Avhere  the  integuments  were  painful  on  pressure,  and,  at 
one  spot  near  the  mastoid  process,  felt  soft  and  elevated.  A  punc- 
ture was  made  at  this  place  with  a  lancet,  but  nothing  was  discharged. 
Topical  bleeding,  blistering,  (fcc,  were  recommended. 

4th. — Pulse  in  the  morning  148 ;  in  the  course  of  the  day  it  fell 
to  84 ;  looking  very  languid  and  exhausted. 

5th. — Dark-colored  matter  of  intolerable  fetor  began  to  be  dis- 
charged from  the  puncture  Avhicli  had  been  made  behind  the  ear. 
The  opening  here  was  enlarged,  and  a  probe  being  introduced,  the 
bone  was  felt  bare  and  rough  over  a  considerable  space ;  headache 
much  relieved  ;  pulse  natural. 

Gth. — Great  discharge  from  the  opening,  headache  much  relieved; 
pulse  112 ;  complained  of  some  pain  in  the  left  side  of  thorax,  and 
there  was  considerable  diarrhoea. 

7th. — No  headache;  there  was  much  discharge  of  fetid  matter 
from  the  opening  near  the  mastoid  process,  and  a  probe  introduced 


THE    MASTOID    CELLS.  335 

by  it  passed  downwards  and  backwards,  under  the  integuments,  as 
far  as  the  spine. 

8th. — Pain  in  the  thorax  continued,  and  was  noAV  so  urgent  that  a 
small  bleeding  was  employed  with  partial  relief;  it  could  not  be 
carried  further  on  account  of  increasing  weakness;  pulse  140. 

9th. — Said  she  felt  better,  and  made  no  complaint  of  pain  ;  pulse 
very  rapid,  and  strength  sinking. 
Died  on  the  10th. 

Autopsy. — Every  part  of  the  brain  was  in  the  most  healthy  state, 
except  a  small  portion  on  the  right  side,  near  the  ear,  which  was  of 
a  dark  leaden  color ;  the  tinge,  however,  was  entirely  superficial. 
The  right  temporal  bone  externally  was  bare,  through  a  great  part 
of  its  extent ;  internally,  it  was  in  many  places  rough  and  dark- 
colored  ;  and  there  was  some  dark-colored  matter  betwixt  it  and  the 
dura  mater.  The  dura  mater  at  this  place  was,  for  a  considerable 
space,  thickened,  spongy,  and  irregular  ;  the  coats  of  the  right  lateral 
sinus  Avere  greatly  thickened  through  its  whole  extent,  and  the 
capacity  of  the  sinus  Avas  very  much  diminished  by  a  deposition 
similar  to  that  Avhich  occurs  in  the  cavity  of  an  aneurism.  The  in- 
ternal ear  contained  dark-colored  matter ;  the  left  cavity  of  the 
pleura  contained  fully  a  pound  of  puriform  fluid ;  the  left  lung  was 
collapsed,  dense,  dark  colored,  and  covered  by  a  coating  of  coagu- 
lable  lymph. 

From  the  examination  made  by  me  of  deposits  in  the  cavity  of 
the  lateral  sinus,  I  have  no  doubt  that  the  matter  alluded  to  in  the 
above  case,  consisted  of  coagulated  blood  mixed  with  pus. 

The  following  is  one  of  Dr.  Watson's  cases  :  "A  boy,  11  years 
old,  had  had  a  discharge  of  offensive,  purulent  matter  from  his  ear 
since  the  time  Avhen,  four  years  before,  he  had  gone  through  an  at- 
tack of  scarlet  fever.  In  August,  1838,  he  Avent  for  a  Avalk  into 
Kensington  Gardens,  and  there  lay  doAvn  and  slept  upon  the  damp 
grass,  .  The  next  day  he  Avas  attacked  with  headache,  shivering,  and 
fever;  strong  rigors,  followed  by  heat  and  perspiration,  occurred 
very  regularly  for  tAvo  or  three  days  in  succession,  suggesting  the 
suspicion  that  his  complaint  might  be  ague ;  but  then  pain  and  swel- 
ling of  some  of  the  joints  came  on,  and  AA'cre  at  first  considered 
rheumatic.  However,  the  true  and  alarming  nature  of  the  com- 
plaint soon  became  apparent ;  abscesses  formed  in  and  about  the 
affected  joints,  and  one  of  these  fluctuating  SAvellings  Avas  opened, 
and  a  considerable  quantity  of  foul,  grumous,  dark-colored  matter 


336  THE     DISEASES     OF    THE    EAR. 

let  out.  After  about  a  fortnight,  the  child  sank  under  the  con- 
tinued irritation  of  the  disease.  The  hip-joint  presented  a  frightful 
specimen  of  disorganization ;  it  was  full  of  unhealthy  sanious  pus  ; 
the  ligamentum  teres  was  destroyed,  the  articular  cartilages  were 
gone  ;  and  matter  had  burrowed  extensively  among  the  surround- 
ing muscles.  The  knee  and  ankle-joints  of  the  same  limb  were  in  a 
similar  condition.  Unfortunately  the  head  was  not  examined,  but 
that  the  fatal  disorder  had  penetrated  from  the  ear  to  the  dura 
mater,  I  entertain  no  doubt;  in  all  probability  the  inflammation  had 
involved  the  veins  or  sinuses  of  the  head." 

Having  given  another  case  of  a  similar  natui'e.  Dr.  Watson 
says : — 

"  I  much  lament  that,  in  these  instances,  the  direct  link  of  con- 
nection between  the  disease  of  the  ear  and  the  disorganization  of 
the  joints  was  not  demonstrated,  for  seeing  (they  say)  is  believing. 
Yet  the  pain  of  the  ear,  the  discharge  of  pus  from  the  external 
meatus,  the  subsequent  pain  in  the  head,  coming  on  with  fever  and 
rigors,  and  followed,  after  a  short  interval,  by  destructive  suppura- 
tion in  several  distant  parts,  and,  in  the  latter  case,  the  actual 
femoral  phlebitis, — these  circumstances  form  a  chain  of  presumptive 
evidence  amounting,  in  my  judgment,  to  moral  certainty,  that  the  ' 
fatal  mischief,  in  each  case,  found  entrance  through  the  porches  of 
the  ear,  and  that  the  dura  mater  underwent  inflammation.  The 
same  evidence  is  scarcely  less  afiirmative  of  the  complication  of 
cerebral  phlebitis.  Perhaps  the  veins  of  the  diploe,  which,  in  the 
cranial  bones,  are  of  considerable  magnitude,  were  involved  in  the 
inflammatory  mischief;  perhaps  the  large  sinuses  of  the  brain.  The 
close  proximity  of  the  lateral  sinus  to  the  diseased  bone,  and  its 
formation  by  a  duplicature  of  the  dura  mater,  would  seem  to  render 
such  a  complication  highly  probable." 

The  direct  link  of  connection  between  the  disease  in  the  ear  and 
that  of  the  circulating  system  was  pointed  out  by  Dr.  Bruce,  and 
also  in  the  case  cited  by  Mr.  Wilde.  In  the  latter,  "  The  membra- 
nous walls  of  the  right  lateral  sinus,  throughout  the  whole  of  the 
mastoid  portion  of  its  course,  were  much  thickened,  and  their  lining 
presented  a  sloughy  appearance,  being  covered  with  lymph  of  a 
greenish  hue,  and  smeared  with  unhealthy  purulent  matter.  This 
condition  of  the  lining  membrane  extended  along  the  jugular  vein 
and  superior  vena  cava  to  within  a  short  distance  of  the  entrance  of 
the  latter  into  the  auricle.     The  left  cavity  of  the  pleura  contained 


THE    MASTOID     CELLS.  337 

about  four  ounces  of  a  thin  fetid  matter."  In  addition  to  the  facts 
above  cited,  all  tliat  is  required  is,  an  account  of  the  exact  condi- 
tion of  the  ear ;  and  this  has  been  supplied  by  me  in  the  following 
case,  which  occurred  to  Dr.  Heale,  at  the  Free  Hospital. 

Case  II.  Pus  in  mastoid  cells  ;  caries  of  the  lateral  sulcus  ;  pus 
in  the  lateral  sinus ;  secondary  deposits. — Harriet  G.,  aged  20,  was 
admitted  into  the  hospital  on  the  9th  March,  1850.  She  had  great 
fluttering  and  irregular  vibrating  action  of  the  heart,  resembling 
erythismus  mercurialis,  but  which  subsided  in  a  day  or  two.  She 
was  deaf  in  the  left  ear,  and  had  long  been  subject  to  intense  ear- 
ache, with  occasional  fetid  discharge  from  the  meatus.  She  was 
restless,  sleepless,  occasionally  delirious,  and  had  no  appetite.  Soon 
after  her  admission,  an  abscess  formed  just  above  the  left  collar-bone, 
which  discharged  large  quantities  of  matter  until  her  decease.  The 
disturbance  of  the  heart's  action  returned  after  three  doses  of  hyd. 
c.  creta,  six  grains  having  been  given  every  six  hours  ;  but  it  again 
subsided  in  about  two  days.  She  then  had  severe  delirium,  which 
abated  after  a  sudden  large  and  fetid  discharge  from  the  left  ear  : 
finally  she  had  erysipelas,  violent  delirium,  succeeded  by  coma,  and 
died  on  the  15th  of  April. 

Autopsy. — A  very  large  excavated  abscess,  with  sinuses  in  vari- 
ous directions,  was  exposed  at  the  root  of  the  neck  on  the  left  side, 
communicating  with  and  extending  through  the  whole  of  the  carotid 
sheath.  The  internal  jugular  vein  was  full  of  matter,  Avhich  was 
also  found  burroAving  down  in  the  direction  of  the  vena  innominata ; 
a  fibrinous  clot  was  found  in  that  vein  extending  into  the  descending 
vena  cava ;  and  having  been  examined  by  the  microscope,  was  found 
to  contain  pus  globules.  The  lungs  were  filled  with  a  frothy  and 
purulent  infiltration,  without  consolidation,  and  there  was  a  small 
circumscribed  absoess  betAveen  the  pleura  pulmonalis  and  the  right 
lung,  which,  however,  did  not  extend  into  the  substance  of  the  latter. 
The  heart  was  healthy  ;  the  liver  pale-colored.  The  cerebrum  was 
healthy ;  the  arachnoid  membrane,  in  parts,  appeared  smeared  over 
with  pus,  more  particularly  in  the  posterior  part,  near  the  falx, 
joining  the  tentorium.  The  tentorium  covering  the  left  lobe  of  the 
cerebellum  was  much  inflamed,  thickened,  and  had  matter  between 
it  and  the  arachnoid  covering  that  lobe  of  the  cerebellum  ;  and  im- 
mediately beneath  this,  on  cutting  into  the  cerebellum,  a  circum- 
scribed abscess,  about  the  size  of  a  walnut,  was  discovered.  This 
was  nearer  to  the  falx  cerebelli  than  to  the  outer  margin  of  the 

22 


:j38  THE    DISEASES     OF    THE    EAR. 

cerebellum  :  the  part  of  the  cerebellum  in  contact  with  the  cranial 
bones  was  healthy. 

The  petrous  bone  was  examined  by  myself,  and  reported  upon  as 
folloAvs  : — 

The  meatus  externus  contained  purulent  matter.  The  glandular 
and  periosteal  portions  of  the  membranous  meatus  were  much  softer 
than  natural,  and  adhered  but  slightly  to  the  surface  of  the  bone. 
The  bone  forming  the  upper  and  outer  half  of  the  tube  was  found 
to  present  numerous  foramina  for  the  transmission  of  bloodvessels, 
which  were  much  larger  than  natural,  and  some  of  them  surrounded 
by  delicate  layers  of  new  bone  :  through  the  larger  of  these  fora- 
mina, good-sized  bristles  could  be  passed,  and  they  appeared  to  com- 
municate with  canals  in  the  interior  of  the  bone,  which  were  them- 
selves continuous  with  orifices  in  the  sulcus  lateralis  at  its  inner 
surface.  The  lateral  sinus  was  of  a  dark  brown  color,  and  the  dura 
mater  formins;  its  exterior  wall  was  entire.  The  sinus  was  full  of 
coagulated  blood,  mixed  with  purulent  matter.  The  dura  mater 
constituting  its  anterior  wall,  and  which  was  in  contact  with  the 
surface  of  the  bone  forming  the  sulcus  lateralis,  was  very  thick  and 
soft ;  portions  of  it  were  destroyed  by  ulceration,  and  the  bone  Avas 
exposed.  This  bone  was  dark  in  color,  and  covered  l)y  masses  of 
lymph  and  pus;  its  surface  was  rough,  presenting  throughout  nume- 
rous orifices  and  tortuous  grooves, — an  appearance  which  was  pro- 
duced by  the  nearly  complete  absence  of  the  internal  table  of  the 
skull,  that  (with  the  exception  of  two  scales,  each  measuring  about 
two  lines  in  diameter)  having  been  destroyed  by  caries. 

A  carious  orifice  existed  between  the  cavity  of  the  cerebellum 
and  the  mastoid  cells.  The  bone  forming  the  jugular  fossa  was  also 
carious.  There  was  an  orifice  in  the  posterior  part  of  the  merabrana 
tympani.  • 

The  tympanic  mucous  membrane  was  much  thicker  than  natural, 
and  in  the  upper  osse9us  wall  were  observed  a  few  small  foramina 
for  bloodvessels,  and  a  carious  orifice  of  a  size  sufficient  to  allow  the 
passage  of  a  small  pin. 

The  mastoid  cells  at  their  upper  part  formed  a  cavity  about  the 
size  of  an  ordinary  horse-bean,  and  contained  pus.  This  cavity 
communicated  posteriorly  with  the  lateral  sulcus  by  means  of  an 
orifice  three  lines  in  diameter.  Anteriorly,  the  orifice  into  the 
tympanic  cavity  was  not  more  than  two  lines  in  diameter,  and  was 
placed  above  the  level  of  the  floor  of  the  cavity  containing  the  pus. 


THE    MASTOID     CELLS.  339 

It  lias  been  already  stated  that  the  anterior  wall  of  the  mastoid 
cells  is  formed  by  the  posterior  wall  of  the  osseous  external  meatus. 
The  latter  wall,  in  some  cases,  becomes  carious,  and  matter  is  dis- 
charged through  it,  as  was  the  case  in  the  following  interesting  in- 
stance, but  the  orifice  was  not  large  enough  to  be  effectual  in  reliev- 
ing the  symptoms. 

Case  III.  Pus  and  scrofulous  matter  in  the  mastoid  cells  ;  commu- 
nication with  the  lateral  sinus  by  the  veins;  secondary  deposit  in  pleura. 
— Kitty  D.,  aged  15,  was  admitted  under  my  care  as  an  out-patient 
of  St.  Mary's  Hospital  on  the  IGth  of  February,  1854.  She  stated 
that  six  months  previously  she  suffered  from  pain  in  the  left  ear, 
Avhich  was  followed  by  dulness  of  hearing  in  it,  as  well  as  in  the 
right  ear,  which  had  remained  to  the  present  time,  accompanied  by 
a  discharge  from  the  left  ear.  On  examining  the  left  ear,  a  small 
red  polj'pus  was  seen  at  the  inferior  part  of  the  meatus,  near  to  the 
mcmbrana  tympani :  the  latter  membrane  Avas  white.  She  did  not 
complain  of  pain  in  the  head.  Gentle  counter-irritation  was  or- 
dered behind  the  car,  which  was  to  be  syringed  with  a  weak  astrin- 
gent lotion.  The  patient  continued  much  the  same  until  March 
27th,  when  she  was  admitted,  in  my  absence,  as  an  urgent  case, 
imder  Dr.  Sibson,  into  the  hospital.  When  admitted,  she  was  par- 
tially unconscious,  extremely  prostrate,  and  could  not  speak  :  the 
skin  was  parched ;  the  tongue  broAvn  and  dry ;  pulse  140,  very  small 
and  thready  :  pupils  sluggish — the  left  rather  more  contracted  than 
the  right.  On  inquiry,  it  was  found  that,  three  days  before,  a  marked 
difference  was  perceived  in  her  manner,  and  attributed  to  the  pain 
in  the  head  and  left  ear,  of  which  she  complained  greatly.  She  was 
unable  to  do  any  work.  On  the  25th,  she  kept  her  bed  ;  on  the  26th, 
she  became  still  worse  ;  and  on  the  27th,  application  was  made  at 
the  hospital.  Upon  being  Seen  by  one  of  the  officers,  she  was  at 
once  admitted.  Stimulants  were  freely  administered,  and  the  pa- 
tient somewhat  rallied :  during  the  night,  she  was  very  restless,  and 
wandered  a  good  deal. 

28th. — Seems  quite  sensible  of  all  that  is  done  to  her,  but  does 
not  speak,  muttering  only  to  herself.  Pulse  140 ;  skin  hot,  though 
some  moisture  is  still  apparent.  Loud  sonorous  rhonchus  of  right 
lung  ;  the  head  is  held  to  the  right  sidej  the  mouth  also  is  drawn  to 
the  right ;  the  nostrils  are  expanded  ;  and  there  is  partial  paralysis 
of  some  of  the  muscles  on  the  left  side  of  the  face.  She  was  sup- 
ported by  stimulants  at  the  same  time  that  a  leech  was  applied  to 


r,40  THE     DISEASES    OF    THE    EAR. 

the  neck.  10  p.m. — A^ery  low,  surface  cold;  skin  clammy;  face 
livid  ;  subsiiltus  tendinum  ;  pulse  feeble  and  irregular. 

2ntli. — Much  as  yesterday;  rambled  during  the  night ;  voids  urine 
involuntarily  ;  tongue  brown  and  moist ;  pulse  140,  very  small. 
During  the  evening  very  low  ;  voided  urine  in  the  bed  ;  muscles 
suddenly  contracting. 

30th. — Slept  badly;  at  times  wandered  much;  breathing  hurried; 
pulse  140  ;  nostrils  dilated.  She  gradually  became  worse,  and  died 
at  2-15  P.M. 

AutojJSi/. — Cerebrum  firm  ;  ventricles  dry  ;  gray  substance  very 
dark.  Over  the  left  lobe  of  the  cerebellum,  at  the  posterior  part  of 
the  petrous  bone,  is  a  dark  bluish  portion,  of  the  size  of  half-a-crown. 
The  gray  matter  of  the  cerebellum  very  blue  to  the  depth  of  one- 
eighth  of  an  inch,  and  beneath  the  discolored  spot  the  substance  of 
the  cerebellum  was  slightly  softened.  There  were  considerable  ad- 
hesions between  the  lungs  and  the  pleura  costalis  ;  and  also  tuber- 
cular deposit  covered  by  an  unhealthy  plastic,  fibrinous  exudation  ; 
the  pleural  cavities  contained  a  pint  of  fluid.  The  dura  mater  form- 
ing the  posterior  wall  of  the  lateral  sinus  (where  it  is  situated  in  the 
temporal  bone)  was  of  a  dark  color  and  soft ;  the  sinus  contained,  at 
its  upper  part,  a  firm  coagulum  of  dark-colored  fibrin  ;  at  its  lower 
part  it  was  full  of  dark-colored  pus.  The  anterior  Avail  of  the  sinus 
was  attached  to  the  bone  much  less  firmly  than  natural.  The  mas- 
toid cells  were  full  of  pus  and  scrofulous  matter  ;  and  their  anterior 
wall  presented  an  orifice,  about  two  lines  in  diameter,  which  opened 
into  the  meatus  externus.  The  incus  and  the  thick  mucous  mem- 
brane around  it  prevented  the  pus  from  escaping.  The  orifices  for 
the  passage  of  the  bloodvessels  from  the  mastoid  cells  to  the  lateral 
sinus  were  somewhat  larger  than  natural. 

It  will  be  observed  that  in  this  case  there  Avas  no  caries  of  the  bone 
towards  the  cerebellum  ;  and  the  only  means  by  which  the  disease 
from  the  nuistoid  cells  could  be  propagated  to  the  cavity  of  the  late- 
ral sinus  must  have  been  the  veins. 

A  sufficient  number  of  facts  have  now  been  cited  to  shoAv  how  very 
insidiously  disease  progresses  from  the  mastoid  cells  to  the  cerebellum 
and  lateral  sinus,  and  to  prove  that  the  sinus  may  become  influenced, 
purulent  matter  developed  within  it,  and  secondary  abscesses  pro- 
duced, without  the  occurrence  of  caries  in  the  bone  forming  the  sinus 
lateralis. 

It  has  been  alreatlv  stated  that  the  cause  of  disease  advancing 


THE     MASTOID     CELLS.  341 

from  the  mastoid  cells  to  the  lateral  sinus  and  the  brain,  is  the 
retention  of  the  dischai-ge  within  these  cells,  instead  of  its  finding  a 
free  egress  throno-h  the  external  meatus. 

In  the  cases  of  death  from  purulent  infection  which  have  been 
detailed,  it  will  have  been  observed  that  there  was  merely  a  small 
aperture  in  the  membrana  tympani,  so  that  only  part  of  the  matter 
could  be  discharged  from  the  mastoid  cells  ;  and  it  seems  to  me 
probable,  that  if,  in  any  way,  a  sufficient  portion  of  the  membrana 
tympani  had  been  removed  at  the  beginning  of  the  attack,  to  permit 
of  a  thorough  evacuation  of  the  contents  of  the  mastoid  cells,  the 
bone  Avould  have  remained  free  from  disease — an  opinion  which 
seems  corroborated  by  the  following  case  :  for  it  will  be  noted  that 
the  scarlet  fever  appears  to  have  attacked  the  mastoid  cells  of  each 
ear  equally.  In  each,  the  lower  half  of  the  membrana  tympani  Avas 
destroyed ;  but  in  the  organ  of  which  the  bone  became  diseased,  it  will 
be  remarked  that  the  lower  margin  of  the  remnant  of  the  membrana 
tympani  fell  inwards  towards  the  promontory,  to  Avhich  it  became 
attached,  and  by  this  means  the  escape  of  matter  from  the  mastoid 
cells  was  prevented  ;  while,  in  the  other  ear,  the  lower  margin  of 
the  membrane  remained  free,  and  the  discharge  readily  escaped. 
The  case,  of  which  the  particulars  were  sent  to  me  by  a  friend, 
togetlicr  Avith  the  petrous  bones,  is  of  importance  on  other  grounds, 
since  it  shoAvs  the  coexistence  of  disease  in  the  mastoidal  and  tym- 
panic cavities,  and  the  contemporaneous  production  of  disease  in  the 
cerebrum  and  cerebellum.  It  is  further  of  interest  as  pointing  out 
how  very  little  relation  exists  betAveen  the  condition  of  the  bone 
forming  the  lateral  sulcus,  and  the  contents  of  the  lateral  sinus. 
In  some  cases  already  described,  the  lateral  sinus  contained  a  large 
quantity  of  pus,  but  the  bone  was  not  carious  ;  whereas  in  the  fol- 
lowing case,  where  the  bone  forming  the  lateral  sulcus  was  so  much 
diseased  that  a  large  portion  Avas  necrosed  and  completely  detached 
from  the  surrounding  parts,  there  was  no  pus  in  the  sinus.  The 
explanation  of  this  circumstance,  found  also  in  other  cases,  is  most 
probably  to  be  sought  for  in  the  fact,  that  Avhen  there  is  extensive 
caries  of  the  substance  of  the  bone,  there  is  more  space  for  the 
matter,  and  hence  the  pressure  upon  the  sinus  is  comparatiA'ely 
slight. 

Case  IV.  Catarrhal  injlammation  of  the  mucous  membrane  lining 
the  mastoid  cells  of  the  ear;  retention  of  the  discharge  in  the  right 
ear  by  the  adhesion  of  the  membrana  tympani  to  the  promontory ; 


342  THE     DISEASES     OF     THE     EAR. 

caries  of  the  right  lateral  sulcus,  and  abscesses  in  the  cerebrum  and 
cerebellum. — J.  R.,  aged  12,  had  an  attack  of  scarlet  fever  two  years 
previously,  since  Avhich  he  has  had  a  discharge  of  matter  from  each 
ear,  and  a  considerable  diminution  of  the  hearing  power.  On  the 
13th  of  February,  1854,  he  complained  of  rigors  and  general 
malaise;  these  were  followed  by  febrile  symptoms  and  pain  behind 
the  left  ear.  On  the  15th,  a  small  abscess  was  observed  behind  the 
ear,  which,  Avhen  opened,  discharged  a  sanguineous  fluid.  There 
was  a  slight  degree  of  stupor,  and  the  discharge  continued  without 
relief  to  the  pain.  On  the  20th,  he  had  somcAvhat  improved  ;  pain 
less  ;  stupor  diminished  ;  discharge  from  the  meatus  as  well  as  from 
the  abscess.  On  the  21st,  another  abscess  formed  over  the  mastoid 
process  ;  pulse  small  and  frequent,  discharge  very  fetid.  22d. — 
Decidedly  improved  in  every  respect  ;  but  the  pain  and  feverish 
symptoms  returned  on  the  23d,  in  an  aggravated  form  ;  the  drowsi- 
ness much  increased,  so  tliat  he  had  to  be  roused  up  to  take  his 
food,  and  he  soon  fell  back  ao;ain  into  the  same  state.  He  jiradu- 
ally  became  weaker;  the  urine  and  fences  were  passed  involuntarily; 
the  stupor  was  increased  ;  and  the  prostration  was  extreme.  On 
the  4th  of  March,  he  had  two  severe  rigors,  and  constantly  cried  out 
on  account  of  the  severe  pain  in  the  head.  The  pain  gradually  in- 
creased till  the  6th  of  March,  Avhen  attacks  of  pain  came  on  every 
ten  minutes,  and  of  so  acute  a  character  as  to  cause  him  to  scream. 
During  the  succeeding  seven  days,  he  suffered  much  less  pain  ;  and 
there  was  a  copious  sanious  discharge  from  the  ear  and  from  the 
abscess.  On  the  15th,  the  stomach  became  irritable,  and  rejected 
everything  introduced  into  it.  The  pain,  at  times,  Avas  extreme. 
On  the  ICtli,  at  tAventy  minutes  past  twelve,  he  suddenly  became 
convulsed,  the  face  and  chest  Avere  of  a  deep  blue,  the  pulse  Avas 
imperceptible  at  the  Avrist,  the  pupils  dilated  and  fixed,  and  in  this 
state  he  died.  Upon  inquiry,  it  appeared  that,  since  the  fever,  the 
patient  had  suffered  from  frequent  headaches,  languor,  and  drowsi- 
ness. 

Autopsy. — The  bloodvessels  of  the  dura  mater  Avere  highly  con- 
gested. In  the  sulcus  lateralis  Avas  a  portion  of  necrosed  bone, 
about  three-quarters  of  an  inch  long,  and  half  an  inch  broad,  and 
quite  detached  from  the  surrounding  bone  :  its  outer  part  formed  a 
portion  of  the  mastoid  process ;  between  this  detached  piece  of  bone 
and  tlie  dura  mater  was  a  large  quantity  of  purulent  matter,  Avhich 
communicated  Avith  the  superficial  abscess  behind  the  ear.     An  ab- 


THE    MASTOID     CELLS.  343 

scess  was  also  found  in  the  substance  of  the  middle  lobe  of  the  cere- 
brum. Upon  examining  the  ear,  the  lower  half  of  the  membrana 
tympani  was  found  to  have  been  destroyed,  and  the  inferior  half  of 
the  upper  part  Avas  attached  to  the  promontory,  so  that  the  upper 
portion  of  the  cavity  of  the  tympanum  was  closed,  and  the  matter 
secreted  there  had  no  exit.  The  tympanic  mucous  membrane  was 
thick,  and  ulcerated  in  parts,  and  the  mastoid  cells  presented  a 
large  cavity  full  of  pus.  In  the  opposite  ear  the  lower  two-thirds 
of  the  membrana  tympani  were  absent,  but  the  upper  part  was  not 
adherent  to  the  promontory  ;  so  that  there  was  ample  room  for  the 
egress  of  discharge  from  the  tympanum.  The  tympanic  mucous 
membrane  was  thick,  but  not  otherAvise  diseased ;  the  bone  was 
healthy. 

A  case  very  similar  to  the  last  cited  was  brought  under  my  notice 
by  Dr.  Ogle,  who  was  so  good  as  to  give  me  the  preparation.  In 
this  case  the  disease  had  made  way  externally,  so  that  the  mastoid 
process  Avas  broken  up,  Avhile  the  sulcus  lateralis  Avas  by  comparison 
but  slightly  affected.  The  veins  seem  to  have  been  the  medium  of 
communication  with  the  lateral  sinus,  and  the  cause  of  the  deposit 
of  pus  within  it.  The  question  Avould  probably  be  asked,  Avhy,  in 
these  cases  of  disease  in  the  mastoid  cells,  does  not  the  matter  make 
its  Avay  outA\'ards  through  the  external  Avail  of  the  mastoid  process  ? 
It  Avill  be  observed,  that  this  outAvard  advance  of  the  disease  has 
already  been  noticed  in  three  of  the  cases ;  but  while  this  Avas  going 
on,  the  internal  Avail  of  the  mastoid  cells,  or  of  the  lateral  sinus, 
became  so  diseased  as  to  destroy  life.  It  must  also  be  borne  in 
mind  that  cases  are  of  very  frequent  occurrence  Avhere  the  disease 
advances  externally,  destroying  part  of  the  mastoid  process,  Avhich 
often  comes  away  en  masse,  and  where  the  brain  and  its  membranes 
suffer  but  slightly.  Cases  of  this  kind  generally  originate  in  an  at- 
tack of  scarlet  fever,  or  of  cold  ;  sometimes  the  symptoms  of  cere- 
bral irritation  are  but  slight,  at  others,  very  severe,  and  usually  sub- 
side Avhen  there  is  a  free  discharge  externally,  as  will  be  seen  AA'hen 
speaking  of  the  treatment. 

In  the  course  of  the  previous  observations,  it  has  been  stated  that 
in  cases  of  disease  Avithin  the  tympanic  cavity  catarrh  of  the  dermoid 
meatus  takes  place,  as  the  result  of  sympathetic  action,  and  Avithout 
the  existence  of  any  orifice  in  the  membrana  tympani.  It  is  impor- 
tant to  bear  this  fact  in  mind,  because  the  attention  of  the  surgeon 
is  apt  to  be  draAvn  from  the  real  disease  tOAvards  the  affection  of  the 


344  THE    DISEASES     OF    THE    EAR. 

meatus  ;  indeed,  in  many  cases  of  irritation  of  the  external  meatus, 
arising  from  obstruction  of  the  Eustachian  tube,  the  primary  disease 
is  often  overlooked,  and  the  cause  of  deafness  supposed  to  reside  in 
the  irritation  of  the  meatus.  The  meatus  externus  not  only  sympa- 
thizes with  the  condition  of  the  tympanic  cavity,  by  becoming  the 
seat  of  catarrh,  but  not  unfrequently  polypi  are  developed  within  it. 
When  tuis  happens  in  cases  where  there  are  symptoms  of  disease  of 
the  bone,  great  care  must  be  taken  not  to  increase  the  irritation  of 
the  ear  by  interfering  with  the  polypus.  The  following  case  is,  in 
this  view,  worthy  of  the  most  attentive  consideration.  It  Avas  laid 
before  the  Pathological  Society  in  1851,  by  the  late  Mr.  Avery,  and 
reported  upon  by  myself. 

Case  V.  Caries  of  the  mastoid  cells  ;  jpolyiyi  in  the  external  mea- 
tus ;  abscess  in  the  cerebellum. — A  man,  aged  35,  had  suffered  for 
some  years  from  frequent  earache  of  a  severe  character,  accompa- 
nied by  discharge.  About  five  weeks  before  his  death  a  large 
polypus  was  removed  from  the  external  meatus.  This  was  followed 
soon  after  by  great  pain  at  the  back  of  the  head,  in  the  right  side, 
and  down  the  neck  and  shoulder,  of  a  plunging  intermitting  cha- 
racter. 

These  pains  were  treated  at  first  as  neuralgic;  but  they  increased 
in  severity  and  frequency,  and  rest  could  only  be  obtained  by  the 
oft-repeated  doses  of  laudanum.  The  patient  appeared  generally  to 
be  dull,  heavy,  stupid,  and  incapable  of  making  any  exertion.  He 
several  times  remarked  that  people  must  have  thought  him  intoxi- 
cated when  in  the  street,  as  his  gait  was  so  very  unsteady  that  he 
was  often  obliged  to  lay  hold  of  the  rails  to  prevent  himself  from 
falling.     He  ultimately  became  comatose  and  died. 

Autopsy. — The  brain  was  found  to  fill  the  cranial  cavity,  and  tlie 
convolutions  were  very  closely  pressed  together.  The  arachnoid 
membrane  Avas  extraordinarily  dry ;  the  lateral  ventricles  contained 
a  very  large  quantity  of  clear  limpid  fluid,  and  the  fornix  and 
septum  lucidum  were  very  white  and  soft.  On  separating  the  cere- 
bellum from  the  petrous  portion  of  the  temporal  bone,  a  gush  of 
thick  creamy  pus  took  place,  and  an  abscess  Avas  found  occupying  a 
cavity  in  the  right  lobe,  large  enough  to  hohl  a  pigeon's  egg.  The 
contents  of  this  caA-ity  Avere  very  fetid,  and  the  Avails  were  firm  and 
lined  by  false  membrane,  being  thin  at  the  point  Avhere  the  cere- 
bellum rested  on  the  aqufcductus  vestibuli  of  the  temporal  bone. 
At  this  spot  there  Avas  a  small  ulcerated  opening  in  the  dura  mater, 


THE    MASTOID     CELLS.  345 

communicating  "with  a  carious  portion  of  temporal  bone,  and  it  was 
here  that  the  disease  had  been  continued  to  the  cerebellum.  There 
was  no  loose  lymph  in  the  cavity  of  the  arachnoid,  and  only  a  thin 
film  covering  it  near  the  ulcerated  opening  in  the  dura  mater.  The 
unsteadiness  of  his  gait,  in  connection  with  the  abscess  in  the  cere- 
bellum, Avas  very  remarkable  ;  but  it  could  not  be  ascertained,  on 
repeated  inquiry,  that  the  want  of  power  over  the  regulations  of  his 
movements  affected  one  side  of  the  body  more  than  the  other. 

Upon  examining  the  petrous  bone,  two  small  polypi  were  found 
attached  to  the  upper  and  posterior  part  of  the  membrana  tympani, 
which  was  very  thick,  and  presented  a  small  orifice  at  its  anterior 
part.  The  membranous  meatus  was  easily  detached  from  the  bone, 
which  was  darker  and  rougher  than  natural.  The  mastoid  cells 
were  carious  and  full  of  pus.  On  removing  the  dura  mater  from  the 
posterior  surface  of  the  petrous  bone,  the  upper  part  of  the  sulcus 
lateralis  Avas  found  to  be  carious  for  a  space  three  lines  in  diameter, 
and  the  orifices  in  the  bone  were  filled  with  fibrin.  The  dura  mater 
coverino;  the  sulcus  lateralis  was  softened,  but  the  disease  had  not 
penetrated  to  the  cavit}^  of  the  sinus.  The  dura  mater  adjacent  to 
the  fossa  jugularis  was  soft  and  partially  destroyed  by  ulceration. 
The  bone  beneath  it  was  carious,  and  Avas  found  to  form  part  of  the 
posterior  Avail  of  the  inner  extremity  of  the  mastoid  cells,  from  Avhich 
the  disease  had  been  propagated. 

In  addition  to  the  other  points  of  interest  in  this  case,  is  the  fact 
that  disease  may  be  propagated  to  the  jugular  vein  from  the  mastoid 
cells,  without  the  intervention  of  the  lateral  sinus. 

I  believe  it  to  be  rare  for  disease  in  the  mastoid  cells  to  manifest 
itself  for  the  first  time  after  the  adult  period.  The  folloAving  is  an 
instance  of  the  kind.  It  is  impossible  to  say  hoAv  long  there  had 
been  incipient  disease ;  but  from  the  appearances  after  death,  it  is 
probable  that  it  was  of  long  standing.  The  case  is  of  great  interest, 
from  the  fact  of  the  existence  of  so  large  an  amount  of  disease,  and 
the  presence  of  formidable  symptoms  for  so  short  a  time  only  before 
death. 

CaseNl.  Caries  of  the  mastoid  cells;  destruction  of  the  sulcus 
lateralis;  pus  discharged  behind  the  ear. — T.  D.,  aged  29,  was  under 
the  care  of  a  friend,  in  May,  1851,  on  account  of  diabetes.  He 
remained  under  treatment  for  ten  Aveeks,  during  Avhich  time  he  did 
not  complain  of  pain  either  in  the  head  or  ear.  At  the  expiration 
of  the  ten  Aveeks  he  went  into  the  country  for  a  fortnight,  and  shortly 


346 


THE     DISEASES     OF     THE     EAR. 


after  liis  return  lie  began  to  speak  of  pain  in  the  liead,  "svhich  was 
principally  referred  to  the  right  mastoid  process.  This  pain,  accom- 
panied by  violent  earache,  gradually  increased,  and  was  attended 
by  a  purulent  discharge  from  the  ear.  Drowsiness,  giddiness,  and 
stupor  supervened.  These  symptoms  were  not  relieved  by  the  most 
active  treatment.  Six  weeks  previous  to  his  death,  an  abscess  was 
opened  behind  the  right  ear,  from  which  a  large  quantity  of  pus  was 
discharged.  No  relief  followed,  the  head-symptoms  gradually  in- 
creasing until  his  death. 

Autopsy. — The  external  meatus  contained  a  large  quantity  of 
muco-purulent  discharge  ;  the  surface  of  its  dermoid  layer  was 
denuded  of  epidermis,  and  its  substance  much  tumefied.  The  meni- 
brana  tympani  was  entire,  but  of  a  dull  leaden  hue,  and  much  softer 
than  natural.  The  cavity  of  the  tympanum  contained  a  great  quan- 
tity of  j)urulent  matter,  and  its  lining  membrane  was  vascular,  thick, 
and  flocculent.  The  incus  had  disappeared ;  the  stapes  was  in  situ, 
but  was  surrounded  1)Y  bands  of  adhesion.     The  osseous  walls  of  the 


Fig. 98. 


The  Right  Petrous  Bone,  showing  the  carious  condition  of  the  Sulcus  Lateralis. 

tympanum  were  healthy.  The  mastoid  cells  were  full  of  purulent 
matter,  and  the  bony  laminix?  dividing  the  cells  were  extensively 
carious,  large  portions  of  them  having  been  destroyed.  The  whole 
of  tlie  posterior  -wall  of  these  cells,  usually  forming  the  sulcus  late- 
ralis, was  completely  destroyed,  and  in  its  place  was  an  orifice  mea- 


THE     MASTOID     CELLS.  347 

snring  an  inch  and  a  quarter  from  above  downwards,  and  more  than 
half  an  inch  in  breadth.  The  orifice  in  reality  corresponded  exactly 
with  the  sulcus  lateralis,  as  situated  in  the  temporal  bone,  with  the 
exception  of  half  an  inch  before  it  reaches  the  fossa  jugularis.  A 
circular  orifice,  about  the  size  of  a  pea,  existed  at  the  posterior  part 
of  the  mastoid  process,  which  communicated  with  the  aperture  just 
mentioned,  on  the  one  hand,  and  with  the  abscess  behind  the  ear,  on 
the  other.  The  membranous  lateral  sinus  was  much  attenuated,  and 
beneath  it  was  a  large  quantity  of  pus.  The  state  of  the  cerebellum 
was  not  reported. 

From  tlie  paucity  of  the  notes  which  accompanied  the  specimen, 
the  cause  of  death  was  not  quite  clear  ;  but  most  probably  there  was, 
in  addition  to  the  other  symptoms,  disease  of  the  cerebellum. 
Probably  the  life  of  this  patient  might  have  been  saved,  if  a  free 
outlet  for  the  discharge  had  been  effected  at  an  earlier  pei-iod.  It 
is  important  to  notice  to  how  great  an  extent  the  osseous  sulcus 
lateralis  Avas  destroyed,  without  ulceration  of  the  lateral  sinus  con- 
tained in  it.     In  this  respect  the  case  is  analogous  to  that  of  P.  R. 

A  case  of  a  similar  character  to  the  last  was  published  by  Mr. 
Gray,  of  St.  George's  Hospital,  in  the  Transactions  of  the  Patlio- 
logkal  Society  for  the  Session  1848-9. 

From  previous  remarks,  it  will  have  been  gathered  that  the  ex- 
istence of  Ions-continued  discharo-e  from  the  ear  of  the  affected  side, 
is  one  of  the  most  frequent  symptoms  attendant  upon  caries  of  the 
mastoid  portion  of  the  bone.  This  discharge  is  usually  accompanied 
by  perforation  of  the  membrana  tympani,  although,  as  has  been 
pointed  out,  the  discharge  usually  comes  from  the  surface  of  the 
meatus,  and  is  purely  sympathetic.  The  case  which  follows  is  of 
interest,  from  the  fact  that  the  membrana  tympani  was  entire,  and 
yet  there  was  slight  discharge  from  the  ear  ;  and  is  further  remark- 
able for  the  short  duration  of  the  chronic  symptoms.  It  Avas  pub- 
lished by  Dr.  Budd,  of  Bristol,  in  the  year  1851,  to  whom  I  am 
indebted  for  the  preparation,  and  for  several  additional  particulars. 

Case  VII.  Catarrh  of  the  mucous  membrane  lining  the  mastoid 
cells  ;  memhrana  tympani  entire  ;  caries  of  the  2)etroushone  ;  abscess 
in  the  cerebellum. — "'  George  Bell,  aged  13,  of  spare  habit  and  deli- 
cate appearance,  but  never  before  the  subject  of  serious  illness,  was 
laid  up,  in  the  beginning  of  June,  1851,  with  an  attack,  which  was 
at  first  considered  to  be  one  of  simple  fever.  Two  circumstances 
were,  however,  remarked,  which  the  sequel  showed  to  be  of  great 


348  THE    DISEASES     OF    THE    EAR. 

importance.  These  Avere  severe  lieadaches,  chiefly  confined  to  the 
right  temporal  region,  and  a  slight  discharge  from  the  right  ear, 
with  severe  deafness  on  the  same  side. 

"  For  the  relief  of  these  complaints,  leeches  were  applied  to  the 
temple  and  behind  the  ear,  followed  by  a  blister  to  the  same  spot. 
Salines  and  a  few  gentle  doses  of  mercury  were  given  internally. 
Under  this  treatment  the  pain  abated,  the  febrile  symptoms  entirely 
subsided,  and  in  the  course  of  a  few  days  the  boy  was  able  to  return 
to  school,  and  resume  his  usual  occupations.  The  pain  in  the  temple, 
however,  never  entirely  ceased.  It  was  described  as  a  dull  pain, 
occasionally  attended  with  throbbing.  Up  to  this  period  there  had 
been  no  vomiting,  and  no  disorder  in  the  motor  or  other  powers  of 
the  nervous  centres. 

"  On  the  12th  of  June,  he  was  again  laid  up,  and  on  the  following 
day  Mr.  Tribe,  his  usual  medical  attendant,  was  sent  for.  The 
pain  in  the  head  had  once  more  become  continuous  and  severe  ;  and 
was  limited  still  more  strictly  than  before  to  the  right  temple,  occu- 
pying, according  to  the  patient's  own  description,  a  space  not 
broader  than  a  crown-piece.  It  was  not  either  acute  or  lancinating. 
There  was  still  great  deafness  in  the  right  ear,  though  the  discharge 
had  ceased.  An  entirely  new  symptom  of  great  significance  was 
now  added.  Two  days  previously,  the  speech  had  become  thick  and 
indistinct,  and  Avas  now  at  times  almost  unintelligible.  Mental 
faculties  unimpaired  ;  memory  accurate  ;  no  strabismus  ;  no  lateral 
or  other  deviation  of  the  tongue ;  no  sickness ;  pupils  somewhat 
dilated,  but  equal  and  sensitive ;  vision  good ;  no  heat  of  surface ; 
no  thirst  ;  extremities  rather  cold  than  otherwise  ;  tongue  moist 
but  thickly  coated ;  bowels  torpid.  Pulse  about  100  in  the  minute, 
weak,  and  fluctuating.  Complexion  pale,  and  countenance  deeply 
marked  with  the  stamp  of  suffering. 

"  On  the  following  day,  his  gait  was  observed  to  be  insecure,  and 
there  was  a  dragging  of  the  right  leg.  The  face  was  also  drawn,  but 
to  wliicli  side  was  not  noted.  The  pain  in  the  licad  had  extended 
itself  across  the  forehead,  and  tlie  patient  had  become  drowsy.  lie 
had  also  vomited  several  times,  rejecting  everything  as  soon  as  taken, 
except  milk,  which  sat  well  on  the  stomach.  The  bowels  had  been 
freely  acted  upon  by  an  aperient,  given  the  day  before. 

"  Under  these  circumstances,  it  was  decided  to  put  the  patient  at 
once  under  the  influence  of  mercury,  and  employ  extensive  counter- 


THE    MASTOID     CELLS.  349 

irritation.  With  this  view,  three  grains  of  blue  pill  were  given  every 
four  hours,  and  a  blister  was  applied  to  the  nape  of  the  neck. 

"  On  the  following  day,  four  grains  of  iodide  of  potassium  Avere 
given  Avith  each  dose  of  blue  pill,  and  a  blister  was  applied  to  the 
shaven  scalp. 

"  On  the  16th,  the  pain  had  extended  to  the  back  of  the  head,  and 
there  was  at  times  double  vision.  The  vomiting  and  drowsiness  con- 
tinued. 

"  On  the  17th,  that  is  to  say,  the  fifth  day  after  the  relapse,  marked 
amendment  set  in.  The  pain  had  much  abated,  being  felt,  in  fact, 
only  when  the  head  was  moved ;  the  utterance  had  become  more 
distinct,  and  the  distortion  of  the  features  had  disappeared  ;  the 
drowsiness  had  ceased,  and  the  vomiting  had  become  much  less  fre- 
quent. There  was  still,  however,  some  slight  thickness  of  speech, 
occasional  double  vision,  and  inequality  of  pulse. 

"■  On  the  19th,  he  had  so  much  recovered  as  to  come  down  stairs; 
and  on  the  20th,  he  dressed  himself  and  descended  without  help. 
During  the  greater  part  of  this  day,  he  amused  himself  with  his 
pencil ;  and  several  complicated  heraldic  drawings,  executed  with 
a  firm  and  clear  outline,  which  are  still  extant,  show,  better  than 
any  other  evidence,  how  entirely  the  right  arm  had  recovered  its 
loss  of  power. 

"Up  to  the  1st  of  July,  the  amendment  had  suifered  no  check; 
and  on  that  day  the  patient  was  down  stairs,  running  about  and 
quite  cheerful.  It  is  worth  notice,  that  he  occupied  himself  a  good 
part  of  that  day  with  a  box  of  carpenter's  tools,  handling  them  with 
his  usual  freedom  and  effect. 

"  As  the  changes  revealed  by  examination  after  death,  coupled 
with  the  history  already  given,  leave  no  doubt  that  at  this  time,  one 
if  not  two  abscesses  of  considerable  size  existed  between  the  folds  of 
the  right  lobes  of  the  cerebellum,  such  an  amount  of  recovery  as  this 
must  be  looked  upon  as  a  very  remarkable  circumstance  ;  and  as  one 
which  might  readily  lead  an  incautious  practitioner  to  give  a  favorable 
prognosis.  The  only  trace  of  cerebral  disorder  still  remaining,  was 
some  slight  thickness  of  speech. 

"  The  hopes  excited  by  this  favorable  change  were,  however,  swept 
away  on  the  following  day,  the  2d  of  July,  by  a  return  of  the  former 
symptoms  in  still  greater  violence  than  before. 

"  On  the  3d  of  July  I  saw  him  for  the  first  time,  in  consultation 


350  THE     DISEASES     OF     THE     EAR. 

with  Mr.  Tribe,  to  whom  I  am  chiefly  indebted  for  the  notes  of  the 
case. 

"  The  condition  of  the  patient  was  then  very  striking,  and  charac- 
teristic of  severe  intercranial  mischief.  The  pain  in  the  head,  at  all 
times  severe,  was  occasionally  so  acute  as  to  extort  moans  and  cries. 
A  very  remarkable  characteristic  of  the  pain,  was  the  intense  degree 
to  which  it  was  aggravated  by  any,  the  slightest,  movement  of  the 
head,  voluntary  or  otherwise.  The  dread  he  showed  at  every  such 
attempt,  could  not  be  readily  forgotten  by  any  one  who  witnessed 
it.  The  chief  seat  of  the  pain  appeared  to  correspond  with  the  base 
of  the  occipital  bone  on  the  right  side  ;  although,  in  less  severity,  it 
affected  the  whole  head.  His  brow  was  deeply  knit,  and  his  whole 
aspect  bore  the  imprint  of  great  suffering.  lie  was  very  drowsy 
withal,  so  that  his  whole  time  was  spent  in  dozing  or  acute  pain. 
He  yawned  frequently  ;  his  pupils  were  much  dilated,  but  equal  and 
sensitive  ;  and  he  was  very  intolerant  of  light.  There  was  no  dis- 
charge from  the  right  ear,  with  Avhich  he  could  hear  the  ticking  of  a 
watch  several  inches  off.  Everything  in  the  shape  of  food  or  medi- 
cine was  vomited  as  soon  as  swallowed ;  the  pulse  varied,  being  at 
the  time  of  my  visit  only  forty  strokes  in  the  minute.  The  belly 
was  deeply  sunken  and  retracted  ;  and  the  skin  peculiarly  dry  and 
harsh.  The  grasp  of  the  right  hand  seemed  to  be  somewhat  less 
firm  than  that  of  the  left,  but  there  was  no  impairment  or  loss  of 
motor  power  (in  the  way  of  paralysis  that  is)  in  an}'  other  part.  His 
mind  was  clear,  and  memory  good  ;  and  his  speech,  though  thick, 
was  sufficiently  intelligible.  There  had  been  no  fit  or  convulsion 
from  the  first.  The  urine  was  scanty,  and  of  high  specific  gravity, 
throwing  down  on  being  boiled,  a  precipitate,  which  was  immediately 
redissolved  on  the  application  of  nitric  acid.  The  tongue  was  coated 
with  a  thick  yellow  paste.  From  this  time  to  the  7th  of  July,  there 
was  little  change,  except  that  the  vomiting  became  gradually  less 
urgent.  On  that  day,  to  the  surprise  of  all,  he  began,  for  the  third 
time,  to  amend  ;  the  pain  in  the  head  abated,  the  drowsiness  lessened, 
and  the  sickness  became  less  and  less  frequent.  From  this  time,  he 
steadily  improved,  and  on  the  13th  of  July  was  so  much  better,  that 
it  was  agreed  that  I  should  susj)end  my  visits  for  some  days.  The 
head  was  now  almost  free  from  pain,  he  moved  with  ease  and  free- 
dom, and  the  vomiting  had  quite  ceased.  His  utterance  became 
much  clearer;  his  tongue  much  cleaner;  he  began  to  take  light  nou- 
rishment Avith  relish  ;  and  his  bowels  acted,  for  the  first  time,  without 


THE     MASTOID     CELLS.  351 

medicine.  Although  there  was  no  derangement  amounting  to  para- 
lysis, he  had  still  a  more  perfect  use  of  the  left  than  of  the  right 
arm  ;  feeding  himself,  for  instance,  by  preference  with  the  left  hand. 

"  On  the  14th  the  patient  was  put  in  a  warm  bath,  Avhich  he 
much  enjoyed  ;  and,  on  being  taken  out,  stood  for  some  time  lean- 
ing for  support  on  his  father's  shoulder.  This  amendment  was, 
however,  of  short  duration. 

"  On  the  following  day  he  became  much  worse,  and  in  the  course 
of  it  was  several  times  seized  with  severe  paroxysms  of  pain,  lasting 
many  minutes.  During  this  time,  the  eyes  were  fixed,  and  the  pupils 
gradually  dilated  more  and  more,  till  the  agony  passed  into  uncon- 
sciousness ;  he  then  remained  for  some  time  in  a  state  of  deep  stupor, 
from  which  he  slowly  recovered.  Although  there  was  no  convulsion, 
each  of  these  attacks  was  followed  by  great  exhaustion. 

"  From  this  period  he  lingered,  with  very  little  change  and  no 
new  phenomena,  until  the  17th  of  July,  Avhen  he  expired  rather 
suddenly,  after  one  of  the  paroxysms  just  described. 

"  The  powers  of  the  left  hand  and  arm  were  unaffected  through- 
out, with  this  single  exception,  that,  for  a  short  time  on  the  9tli  of 
July,  the  fingers  were  spasmodically  bent  on  the  hand.  He  helped 
himself  to,  a  cup  of  coifee  without  difficulty  with  that  hand  about  half 
an  hour  before  his  death. 

"  The  principal  agents  employed  in  his  treatment  were  bitters, 
and  mercury,  both  internally  and  by  inunction.  Latterly  opiates 
were  given  to  lull  the  pain,  and  alkalies  for  the  sickness  ;  but  the 
latter  with  little  or  no  effect. 

"  The  body  was  examined  twenty-six  hours  after  death.  On  open- 
ing the  head,  the  ventricles  of  the  brain  were  found  to  be  enormously 
distended  Avitli  perfectly  transparent  serous  fluid,  the  quantity  of 
which  was  not  measured,  but  must  have  amounted  to  at  least  half  a 
pint ;  one  of  the  ventricles  was  in  fact  accidentally  opened  by  the 
saw  in  removing  the  skull-cap,  although  the  brain  was  by  no  means 
deeply  wounded.  The  convolutions  of  both  hemispheres  were  so 
much  flattened  by  the  pressure,  that  the  sulci  between  them  were 
entirely  efi'aced.  On  pursuing  the  examination,  the  explanation  of 
this  state  of  things  was  found  in  the  condition  of  the  venae  Galeni, 
which  were  flattened,  and  contained  no  blood  ;  the  return  of  blood 
through  them  had  been  obstructed  by  the  pressure  of  underlying 
disease,  and  dropsy  of  the  ventricles  had  resulted.  A  few  transpa- 
rent and  very  minute  granulations,  which  Avcre  only  visible  when 


352  TUE    DISEASES     OF    THE    EAR. 

looked  at  obliquely,  -were  scattered  over  the  arachnoid  at  the 
base  of  the  brain.  "With  this  exception,  the  state  of  the  cerebral 
membranes,  uhether  of  the  surface  or  ventricles,  was  perfectly 
normal ;  they  presented  no  trace  of  inflammation,  and  the  structure 
of  the  brain  itself  was  sound.  The  inferior  surface  of  the  riffht 
lobe  of  the  cerebellum  was  attached  to  the  dura  mater  by  slight 
adhesions.  On  further  examination,  this  lobe  was  found  to  be  the 
seat  of  three  distinct  abscesses ;  two  of  which  were  situated  between 
a  duj)lication  of  the  deep  folds  which  traverse  the  lower  surface  of 
the  cerebellum.  It  is  important  to  remark  in  reference  to  the  his- 
tory of  the  case,  that  their  presence  involved  no  breach  of  fibre  or 
other  structure,  although  from  their  size  they  must  have  exerted 
severe  pressure  on  the  surrounding  parts.  One  of  them  was  about 
the  size  of  a  Spanish  nut,  the  other  would  easily  have  contained  a 
large  walnut.  Both  were  lined  by  a  distinct  membrane,  of  new  for- 
mation, to  which  a  somewhat  thick  layer  of  concrete  pus  was  adhe- 
rent. These  characters  were  best  marked  in  the  smaller  of  the  two 
abscesses,  which,  if  any  inference  may  be  drawn  from  such  appear- 
ances, appeared  to  be  the  older  of  the  two.  The  third  abscess  was 
still  larger,  and  was  formed  at  the  expense  of  the  substance  of  the 
cerebellum  itself.  The  central  part  of  the  right  lobe  w;\s  almost 
entirely  converted  into  pus,  so  that  the  Avhole  of  this  lobe  might  be 
represented  as  a  bag  of  matter  whose  walls  were  formed  by  gray 
substance.  The  small  portion  of  white  substance  still  remaining 
was  broken  up,  and  consisted  chiefly  of  diflluent  pulp.  At  one 
point,  corresponding  to  the  root  of  the  rhomboidal  body,  a  small 
extravasation  had  occurred.  .This  abscess  was  lined  by  no  mem- 
brane, and  had  no  definite  wall,  the  part  in  which  the  suppuration 
was  complete  shading  off"  gradually  into  brokeu-up  nervous  tissue. 
The  pus  it  contained  was  also  much  more  fluid  than  that  of  the 
other  abscesses.  From  these  characters  there  can  be  little  doubt 
that  it  was  the  most  recent  of  the  three.  The  left  lobe  and  other 
parts  of  the  cerebellum  were  free  from  disease.  On  examining  the 
interior  of  the  skull  itself,  a  yellow  spot,  about  the  size  of  a  pea, 
was  discovered  over  the  petrous  portion  of  the  right  temporal  bone. 
The  dura  mater  was  here  separated  from  the  skidl  beneath  by  a  thin 
layer  of  concrete  pus  lying  upon  the  carious  bone ;  but  there  was 
no  trace  of  inflammation  or  other  disease  in  the  cerebral  aspect  of 
the  membrane.  Over  this  space  the  bone  was  destroyed  in  its  whole 
thickness,  so  that,  on  lightly  scraping  it  with  a  scalpel,  the  cavity 


THE     MASTOID     CELLS.  353 

of  the  tympanum  was  brought  into  view.  This  cavity  was  filled 
with  opaque  lymph,  of  a  reddish-yellow  color,  but  on  its  removal 
the  proper  bones  and  muscular  apparatus  of  the  ear  were  seen  to 
be  still  in  place.  The  membrana  tympani  Avas  slightly  thickened 
and  opaque  ;  but  with  this  exception  Avas  sound,  as  was  also  the 
meatus  externus.  It  was  ascertained  that  the  lungs  were  free  from 
tubercle,  and  the  heart  healthy ;  but  the  other  viscera  were  not 
minutely  examined." 

Upon  carefully  inspecting  the  bone,  it  was  evident  that  this  case 
formed  no  exception  to  the  general  rule  laid  down  b}'  me,  that  when 
disease,  beginning  in  the  mastoid  cells  after  the  second  or  third  year 
of  life,  injures  the  brain,  the  cerebellum  is  the  part  affected  ;  for  it 
is  clear  that  the  part  principally  involved  lies  posterior  to  the  small 
bones,  and  that  it  is  in  reality  included  in  the  mastoid  cells. 

This  case  gives  rise  to  one  or  two  other  important  considerations : 
and  first  as  to  the  duration  of  the  disease  of  the  ear.     Dr.  Budd 
informs  me,  that  the  earliest  history  he  had  of  any  affection  of  the 
ear  was,  that  two  months  before  the  fatal  illness,  the  boy  had  been 
kept  from  school  for  two  days  by  a  slight  earache,  but  the  attack 
seemed  to  go  off.     This  attack  of  earache  followed  an  illness  sup- 
posed to  be  scarlatina,  and  it  is  probable  that  the  attack  was  the 
exciting  cause  of  the  urgent  symptoms  ;  but  considering  the  carious 
condition  of  the  petrous  bone,  and  the  presence  of  the  abscess  in  the 
cerebellum,  there  can,  it  appears  to  me,  be  but  little  doubt  that  the 
disease,  in  a  chronic  form,  had  been  in  existence  for  a  considerable 
period.     In  a  letter  to  me.  Dr.  Budd  says :  "  It  is  difficult  to  find  a 
satisfactory  reason  why  a  carious  condition  of  the  posterior  part  of 
the  petrous  bone  should  give  rise  to  abscess  in  the  cerebellum,  and 
caries  of  the  superior  part  to  abscess  in  the  cerebrum  ;  but  it  seems 
to  me  that  the  difficulties  are  fewer  under  the  supposition  that  the 
disease  is  generally  propagated  by  the  veins  than  under  any  other. 
In  the  case  of  George  Bell,  the  notion  of  propagation  by  direct 
proximity  was  out  of  the  question ;  for  not  only  was  the   carious 
bone  at  a  considerable  distance  from  the  cerebellum,  but  no  morbid 
change  of  any  kind  could  be  detected  in  the  cerebral  aspect  of  the 
dura  mater  covering  the  carious  part.     Many  other  reasons,  if  neces- 
sary, could  be  given   for  believing  that  in  this  and  many  similar 
cases,  the  veins  were  the  channel  of  the  mischief.     That  it  should 
have  had  (as  under  this   supposition  it  would)  to  run  counter  for 
some  distance  to  the  current  of  the  blood  is  no  real  diflficulty  ;  since 

23 


354  THE     DISEASES    OP    THE    EAR. 

in  the  inflammation  of  the  femoral  vein  which  is  set  up  by  diseased 
conditions  of  the  uterus,  and  still  more  by  intestinal  ulcer,  we  have 
undoubted  and  frequent  examples  of  such  a  course  :  it  would  at  the 
same  time  be  going  too  far  to  deny  that  in  some  cases,  especially 
Avhere  the  abscess  is  seated  in  the  brain,  the  disease  is  propagated 
by  direct  continuity."  Several  cases  have  been  seen  by  me  in 
which,  in  a  spot  exactly  corresponding  with  the  cerebral  mischief, 
the  dura  mater  was  either  ulcerated  through,  or  manifestly  diseased. 
From  the  peculiar  discoloration  of  the  parts  in  many  such  cases,  I 
should  suppose  the  putrefactive  decomposition  of  the  carious  dis- 
charges has  much  to  do  in  the  extension  of  the  disease.  With 
regard  to  the  mode  in  which  the  disease  is  propagated  from  the  ear, 
there  appears  to  me  no  doubt  that  the  dura  mater  is  affected  by 
direct  continuity.  To  the  lateral  sinus  there  seems  abundant  evi- 
dence that  it  is  communicated  by  the  bloodvessels  ;  and  although  it 
is  impossible  to  disprove  the  statement  of  Dr.  Budd,  that  the  disease 
extends  to  the  brain  through  the  blood  also,  it  has  always  appeared 
to  me  probable,  that  the  existence  of  an  abscess  in  the  bone  has  by 
sympathy  caused  a  similar  disease  to  be  developed  in  the  brain.  It 
is  quite  certain  that  it  does  not  take  place  by  continuity,  inasmuch 
as  a  considerable  layer  of  healthy  brain  often  intervenes  between 
the  petrous  bone  and  the  abscess  in  the  cerebrum. 

It  has  been  before  stated,  that  disease  of  the  mastoid  cells  pro- 
duces death  by  causing  suppuration  of  the  lateral  sinus,  inflamma- 
tion of  the  membranes  of  the  cerebellum,  or  an  abscess  in  the  sub- 
stance of  the  latter ;  cases  are,  however,  sometimes  met  Avith  in 
which  the  pneumo-gastric  nerve  is  affected  as  it  emerges  through  the 
foramen  laccrum  posterius.  A  case  of  this  kind  occurred  to  Mr. 
Coe,  of  Bristol,  and  was  brought  before  the  Bath  and  Bristol  Branch 
of  the  Provincial  Association,  in  December,  1854.  I  give  it  in  Mr. 
Coe's  words  : — 

Case  VIII.  Disease  of  the  mastoid  cells,  advancing  to  the  lateral 
sinus  and  pneumo-gastric  nerve. — "  An  out-patient  of  the  Bristol 
General  Hospital  came  under  my  care,  complaining  of  running  at 
the  right  ear,  which  had  existed  for  some  years,  and  occasional 
paroxysms  of  acute  pain  in  the  car  and  head  wlienever  the  discharge 
ceased  for  a  time,  such  being  the  case  at  the  period  of  application. 
Leeches  were  applied  to  tlie  mastoid  process,  and  warm  fomentations 
to  the  side  of  the  head,  and  mercury  was  given  internally.  On  the 
next  day  symptoms  of  meningitis  having  come  on,  the  patient  was 


THE    MASTOID     CELLS.  6bb 

taken  into  the  house.  He  progressed  favorably  for  some  days ;  but 
afterwards  began  to  complain  of  stiffness  and  pain  in  the  right  side 
of  the  neck,  and  sudden  attacks  of  difficulty  of  breathing,  as  if  from 
spasm  of  the  glottis.  There  was  a  distinct  rope-like  swelling  de- 
scending from  the  base  of  the  skull,  down  the  side  of  the  neck,  in 
the  situation  of  the  carotid  sheath  :  it  was  very  tender  to  the  touch. 

"  The  diagnosis  was  caries  of  the  posterior  portion  of  the  temporal 
bone ;  meningitis ;  obstruction  of  the  right  lateral  sinus,  either  from 
extension  of  inflammation  or  from  secondary  purulent  deposit ;  sub- 
sequent coagulation  of  blood  in  the  internal  jugular  vein;  inflamma- 
tion of  its  sheath,  with  involvement  of  the  pneumo-gastric  nerve, 
especially  the  inferior  laryngeal  nerve  (the  phenomena  of  the  irrita- 
tion of  this  branch,  being,  at  any  rate,  more  manifested  than  of  any 
other  portion  of  the  nerve). 

"  The  correctness  of  the  diagnosis  was  proved  by  the  2)ost-mortem 
examination." 

Mr.  Leonard,  of  Bristol,  brought  forward  a  case  at  the  same 
meeting,  in  Avhicli  the  pneumo-gastric  nerve  was  implicated,  and  it 
is  interesting  to  find  that  the  cases  of  these  gentlemen  are  considered 
by  them  corroborative  of  the  opinion  advanced  by  me,  "that  the 
parts  of  the  encephalon,  secondarily  affected  in  caries  of  the  petrous 
part  of  the  temporal  bone,  vary  according  to  the  situation  of  the 
caries." 

In  concluding  this  account  of  the  pathology  of  the  mastoid  cells, 
let  me  glance  at  a  peculiarity  sometimes  met  with  in  these  cases, 
viz.,  their  being  attended  with  symptoms  exactly  resembling  remit- 
tent fever. 

Dr.  Griffin,  in  the  Dublin  Journal  of  Science,  published  two  cases 
of  the  kind.  One  of  them,  which  is  also  cited  by  Dr.  Watson,  is  as 
follows : — 

A  young  man,  previously  healthy,  Avas  attacked  with  fits  of  shiver- 
ing, accompanied  by  pain  in  the  left  side  of  the  head.  At  first  the 
paroxysms  were  rather  irregular,  but  they  soon  assumed  the  form 
of  tertian  ague,  coming  on  every  other  day,  at  about  the  same  hour : 
the  cold  fit  commencing  at  noon,  and  lasting  about  half  an  hour, 
followed  by  a  hot  stage  of  somewhat  longer  duration,  and  termina- 
ting in  a  profuse  sweat.  In  the  intermissions  the  pain  in  the  head 
was  trifling ;  there  was  no  thirst  nor  heat  of  skin,  but  he  did  not 
sleep.  A  tumor  formed  over  the  mastoid  process  of  the  left  side, 
and  was  opened,  and  a  quantity  of  extremely  offensive  brownish  pus 


356  THE    DISEASES    OF    THE    EAR. 

sprang  out  with  great  force.  This  gave  much  relief.  The  bone 
was  carious  over  a  space  as  large  as  a  shilling.  After  about  ten 
days,  the  pain  in  the  head  and  in  the  mastoid  process  became  very 
severe  ;  the  patient  had  violent  shivering  fits  many  times  in  the  day, 
great  thirst,  heat  of  skin,  vomiting,  and  delirium ;  his  face  was 
flushed,  and  his  pulse  hard  ;  and  he  died  within  a  few  hours  of  the 
accession  of  these  last  symptoms. 


(<?.)    NECROSIS    OF   THE    MASTOID    PROCESS. 

On  account  of  their  position  and  peculiar  arrangement,  disease  of 
the  mastoid  cells  is  usually  of  a  more  serious  character  than  disease 
of  the  tympanum.  The  difference  between  the  construction  of  these 
cells  in  childhood  and  in  the  adult  has  been  already  described,  and 
it  will  have  been  seen  that  in  each  period  of  life,  during  disease, 
there  is  scarcely  any  possibility  of  the  whole  of  the  secreted  matter 
being  discharged  from  the  ear. 

In  childhood,  before  the  mastoid  process  is  developed,  the  rudi- 
mental  cells,  as  stated,  are  placed  posteriorly  and  superiorly  to  the 
tympanic  cavity,  and  are  bounded  externally  by  a  portion  of  the 
squamous  bone.  In  the  instances  already  detailed  of  disease  occur- 
ring in  these  cells  during  childhood,  it  has  been  shown  that  it 
advanced  rapidly  until  it  caused  the  death  of  the  patient ;  indeed, 
in  those  cases  the  brain,  or  its  membranes,  were  most  probably 
affected  long  before  the  patient's  friends  applied  for  relief,  and  be- 
fore the  diseased  portion  of  bone  had  become  detached,  or  partially 
detached,  so  as  to  admit  the  free  egress  of  the  matter  from  the 
mastoid  cells.  An  examination  of  a  specimen  illustrative  of  this 
branch  of  the  pathology  of  the  subject  will  show,  that  had  the  por- 
tion of  necrosed  bone,  forming  the  outer  wall  of  the  mastoid  cells, 
been  capable  of  removal  during  the  life  of  the  patient,  the  progress 
inwards  to  the  brain  would  probably  have  been  arrested  or  averted. 
In  the  majority  of  cases  of  necrosis  of  the  mastoid  process  which 
fall  under  notice  among  the  out-patients  of  St.  Mary's  Hospital, 
the  portion  of  necrosed  bone  does  become  detached  before  the  mem- 
branes of  the  brain  are  affected,  and  frequently  the  mass  of  bone 
comes  away  with  but  very  slight  cerebral  disturbance.  Indeed,  as 
a  rule,  when  the  portion  of  necrosed  bone  is  detached,  although  it 


THE     MASTOID    CELLS.  357 

may  be  of  considerable  size,  tliere  is  very  little  fear  of  injury  to  the 
brain  or  the  dura  mater. 

It  is  not  always  very  easy  to  distinguish  between  disease  in  the 
tympanic  cavity  and  that  occurring  in  the  mastoid  cells.  As  a 
general  rule,  Avhen  the  mastoid  cells  are  affected,  the  pain  is  referred 
to  the  region  of  the  mastoid  process,  or  to  the  back  of  the  head ; 
tenderness  is  experienced  upon  gently  tapping  or  pressing  upon  the 
mastoid  process ;  the  attacks  of  pain  and  giddiness  appear  more  in 
the  shape  of  sudden  paroxysms,  and  the  giddiness  is  more  violent. 
It  not  unfrequently  occurs  that  there  is  no  perforation  of  the  mem- 
brana  tympani,  though  the  disease  in  the  mastoid  cells  causes  irrita- 
tion and  catarrh  of  the  dermoid  meatus. 

The  following  particulars  relate  to  what  may  be  considered  one 
of  the  most  favorable  eases  of  caries  of  the  mastoid  process. 

Chronie  eatarrh  of  tlie  inueous  rnemhrane  lining  the  mastoid  cells; 
caries  of  the  hone  ;  removal  of  the  dead  portion  ;  recovery. — Master 
W.,  aged  6,  was  brought  to  me  on  the  4th  of  September,  1853. 
His  mother  said,  that  four  years  previously  he  had  an  attack  of 
scarlet  fever,  followed  by  discharge  from  both  ears,  and  by  dulness 
of  hearing.  After  the  discharge  had  continued  for  three  months, 
with  pain  at  the  back  of  the  head,  and  frequent  giddiness,  an  abscess 
formed  behind  the  right  ear,  which  being  laid  open,  a  portion  of 
dead  bone  was  felt,  which  gradually  became  detached  and  was  re- 
moved. The  discharge  from  the  ear  continued.  On  examination 
of  the  right  ear,  the  membrana  tympani  was  absent,  and  the  meatus 
contained  polypi.  In  the  left  ear,  the  membrana  tympani  was  per- 
forated ;  the  mucous  membrane  of  the  tympanum  was  red,  and 
poured  out  an  abundant  discharge.  Posterior  to  this  ear  was  a 
small  orifice,  through  which,  by  means  of  a  probe,  dead  bone  was 
felt.  This  was  the  upper  part  of  the  mastoid  process,  which,  by 
slow  degrees,  was  detached  and  removed.  After  its  removal,  and 
the  constant  use  of  the  syringe  and  warm  water,  the  discharge  dis- 
appeared. 

A  large  number  of  cases,  very  similar  in  detail  to  the  above, 
might  be  added.  Sometimes  the  head-symptoms  are  slight,  at  others 
very  marked.  There  is  usually  polypus  in  the  meatus,  resulting 
from  the  irritation  of  the  dead  bone.  If  it  seriously  interferes  with 
the  outward  progress  of  the  dead  bone,  the  polypus  may  be  removed  ; 
otherwise  it  Avill  generally  be  found  to  disappear  after  the  discharge 
of  the  bone.     In  many  cases  which  have  fallen  under  my  notice,  the 


358  THE    DISEASES     OF    THE     EAR. 

portion  of  necrosed  bone  has  been  removed  from  the  meatus,  without 
any  incision  being  made  over  the  mastoid  process :  a  plan  which 
may  usually  be  adopted,  since  the  membranus  meatus  is  capable  of 
being  greatly  dilated,  and  the  disfigurement  is  thus  less  than  •when 
an  incision  is  made. 

It  not  unfrequently  happens,  that  the  loss  of  a  considerable  por- 
tion of  the  mastoid  cells  is  unattended  with  any  more  serious  dimi- 
nution of  the  hearing  power  than  that  accompanying  simple  catarrh 
of  the  mucous  membrane  of  the  tympanum,  accompanied  by  ])artial 
or  complete  loss  of  the  membrana  tympani.  Paralysis  of  the  portio 
dura  nerve  is,  however,  a  not  uncommon  result.  This  nerve,  it  will 
be  remembered,  passes  internal  to  the  mastoid  process,  and  is  apt 
to  become  involved  in  the  disease  of  the  bone,  as  in  the  following 
cases. 

Catarrh  of  the  mucous  membrane  of  the  tympanum  and  mastoid 
cells  after  scarlet  fever ;  caries  of  the  mastoid  pt'ocess;  paralysis  of 
the  portio  dura  nerve. — Master  C,  aged  5,  was  brought  to  consult 
me  on  the  8th  of  February,  1853.  His  history  is,  that  seven 
months  ago  he  had  an  attack  of  scarlet  fever,  which  was  followed, 
a  fortnight  after,  by  a  discharge  from  each  ear,  the  loss  of  the  small 
bones,  and  complete  deafness,  so  that  he  does  not  hear  a  sound.  On 
examining  the  right  ear,  the  membrana  tympani  and  ossicles  were 
absent,  the  mucous  membrane  of  the  tympanum  Avas  red  and  thick, 
and  pouring  out  a  copious  discharge  of  mucus. 

Left  car. — The  meatus  contains  a  large  polypus,  below  which  is  a 
portion  of  necrosed  mastoid  process,  that  moves  on  being  touched 
with  a  probe.  The  left  portio  dura  nerve  is  paralyzed.  The  course 
of  treatment  recommended  consisted  in  the  use  of  a  syringe  and 
warm  Avater  daily,  and  in  the  administration  of  tonic  medicines. 
In  the  course  of  a  fortnight,  the  portion  of  dead  bone  gradually 
Avorkcd  its  Avay  to  the  orifice  of  the  meatus,  and  Avas  removed  ;  it 
was  about  half  an  inch  in  length,  and  a  quarter  of  an  inch  in 
breadth.  After  the  bone  Avas  extracted,  the  polypus  disappeared, 
and  the  discharge  ceased. 

Sometimes,  as  in  the  next  case,  the  cerebral  symptoms  are  of 
great  severity. 

Caries  of  the  mastoid  cells;  severe  cerebral  sympt07us;  paralysis 
of  the  jjortio  dura  nerve. — Miss  J.  S.,  aged  6|,  pale  and  sickly,  Avas 
brought  to  me  on  the  14th  of  August,  1850,  Her  mother  stated, 
that  a  day  or  tAvo  after  her  birth  a  discharge  Avas  seen  to  issue  from 


THE     MASTOID    CELLS.  359 

the  tube  of  each  ear,  but  more  abundantly  from  the  left.  The  right 
ear  recovered,  except  a  slight  occasional  discharge,  but  it  was  con- 
stant on  the  left  side  ;  and  at  the  age  of  two  years  was  followed  by 
an  abscess  at  the  back  of  the  ear,  accompanied  by  violent  pain  in 
the  back  part  of  the  head,  giddiness,  and  partial  insensibility. 
After  the  abscess  had  remained  open  between  two  and  three 
months,  a  rounded  portion  of  dead  bone,  of  the  size  of  a  large 
horse-bean,  came  away,  and  about  this  time  the  child  lost  the  use  of 
the  muscles  of  the  left  side  of  the  face.  When  seen  by  me,  there 
was  so  great  a  dulness  of  hearing  that  she  had  to  be  loudly  spoken 
to  within  the  distance  of  a  yard.  The  membrana  tympani  of  each 
ear  was  absent ;  the  tympanic  mucous  membrane  was  red  and  thick, 
and  there  was  a  depression  behind  the  left  ear,  from  which  the  piece 
of  dead  bone  had  been  removed.  The  treatment  pursued  consisted 
in  the  use  of  frequent  injections  with  warm  water,  folloAved  by  mild 
astringents.  Gentle  counter-irritation  was  kept  up  behind  each 
ear,  and  tonic  medicines  administered.  Under  these  plans  the 
discharge  gradually  subsided,  and  the  power  of  hearing  somewhat 
improved. 

Treatment  in  the  adult. — In  the  adult,  the  mastoid  process  rarely 
comes  away  in  a  considerable  portion  ;  and  the  outer  surface  is  so 
dense,  that  the  only  way  in  Avhich  discharge  escapes  from  the  inte- 
rior is  through  a  small  fistulous  orifice.  The  inner  wall  of  the  mas- 
toid cells  is  usually  the  first  to  yield,  and  the  sulcus  lateralis  is 
partially  or  wholly  destroyed,  as  has  been  shown  by  cases  already 
quoted.  The  cause  of  the  inward  progress  of  the  matter  is,  doubt- 
less, the  difficulty  of  its  escape  outAvards.  In  some  cases  where  the 
membrana  tympani  has  been  wholly  destroyed,  and  where  the 
mucous  membrane  of  the  tympanum  is  not  so  thick  as  to  close  or 
very  much  diminish  the  aperture  from  the  mastoid  cells,  a  certain 
quantity  of  the  matter  can  escape  through  the  tympanum  into  the 
meatus  ;  but  often  the  membrana  tympani  is  either  entire,  or,  as  in 
one  case  already  cited,  its  lower  margin  is  attached  to  the  promon- 
tory, and  effectually  precludes  the  escape  of  the  discharge. 

It  is  unnecessary  to  repeat  the  remarks  already  made  as  to  keep- 
ing an  opening  in  the  membrana  tympani.  When  that  membrane 
is  evidently  preventing  the  egress  of  the  matter,  and  where  the  irri- 
tation produced  by  the  operation  is  not  to  be  feared,  there  can  be  no 
harm  in  trying  the  effect  of  a  puncture.  Perforation  of  the  mastoid 
process  also  suggests  itself,  and  this  operation  may,  doubtless,  be 


360  THE     DISEASES     OF     THE     EAR. 

performed  in  those  cases  M'licrc  the  matter  is  pent  up  in  the  cavity 
of  tlie  ear,  and  is  causing  such  urgent  and  serious  symptoms,  as  are 
likely,  if  not  relieved,  to  terminate  in  death.  I  have  never  per- 
formed this  operation,  but  I  should  not  scruple  to  do  so  in  a  case 
■where  the  life  of  the  patient  -was  threatened.  Considering  the  large 
extent  of  the  mastoid  cells,  it  appears  to  me,  that  the  best  plan  of 
operating  -would  be  to  use  a  trephine  over  the  middle  and  posterior 
part  of  the  process,  and  to  remove  a  portion  of  bone  three-quarters 
of  an  inch  in  diameter.  It  might  be  imagined,  that  when  the  dis- 
ease has  advanced  so  far  as  to  produce  coma,  all  attempts  to  give 
relief  by  making  an  outlet  for  the  matter  would  be  ineffectual. 
Such,  however,  is  not  the  case ;  for  in  one  instance  related  by  Dr. 
Abercrombie,  a  young  lady,  wlio  had  laid  for  three  or  four  days  in 
a  state  of  perfect  coma,  and  whose  situation  was  considered  to  be 
perfectly  hopeless,  was  immediately  and  permanently  relieved  by  a 
sudden  discharge  of  matter  from  the  affected  ear.  Dr.  Abercrom- 
bie  adds,  "It  is,  however,  by  no  means  certain,  that  in  such  a  case 
as  this,  the  discharge ,  came  from  the  cavity  of  the  cranium  ;  for 
there  is  reason  to  believe  that  extensive  suppuration  within  the 
cavity  of  the  tympanum  is  capable  of  producing  symptoms  of  great 
urgency,  especially  if  there  should  be  any  difficulty  of  finding  an 
outlet." 

The  treatment,  however,  on  which  it  seems  to  me  safest  to  rely 
for  promoting  the  absorption  of  the  matter  and  preventing  its  secre- 
tion, so  as  to  bring  back  the  ear  to  a  more  healthy  condition,  is 
counter-irritation,  combined  with  plans  for  improving  the  general 
health.  The  following  case  thus  treated  is  one  of  great  interest,  as 
from  the  symptoms  manifest  when  the  patient  was  first  seen  by  me, 
there  is  no  doubt  that  both  dura  mater  and  bone  were  affected. 

Disease  of  the  mastoid  cells  ;  giddiness  ;  great  pain  in  the  head  ; 
cured  by  the  use  of  a  scton. — R.  D.  M.,  a  clergyman,  aged  42,  tall 
and  thin,  and  not  robust,  consulted  me  on  the  recommendation  of 
Professor  Miller,  of  Edinburgh.  The  history  of  the  case  is,  that 
since  a  child,  after  an  attack  of  earache,  has  had  discharge  at  times 
from  the  left  ear  until  the  age  of  24 ;  from  24  to  82  had  but  one 
attack  of  pain  and  discharge;  between  32  and  35  had  several  severe 
attacks  of  pain  at  intervals  of  a  few  months ;  at  the  age  of  35  had 
a  severe  attack  of  pain,  after  which  such  attacks  became  frequent, 
and  the  discharge  became  constant  and  fetid ;  at  times  serous,  at 
others  purulent  or  bloody.     By  degrees  fits  of  confusion  and  giddi- 


THE    MASTOID     CELLS.  3G1 

ness  in  the  head  supervened,  leading  to  prostration  of  nervous 
energy,  and  a  constant  feeling  (to  use  the  patient's  words)  "  as  if 
he  were  on  the  brink  of  apoplexy." 

About  four  months  previous  to  consulting  me,  he  exerted  himself 
greatly  in  preaching  on  one  occasion.  On  the  same  evening,  he 
afterwards  sat  listening  long  to  a  speaker  in  a  public  debate,  Avith 
his  head  resting  on  his  right  arm.  On  rising  up,  he  was  seized  with 
giddiness  and  a  numb  feeling  in  the  right  arm,  while  his  pulse  Avas 
slow  and  laboring.  He  got  home  Avith  diflBculty;  but,  under  the  in- 
fluence of  rest  and  gentle  purgatives,  he  speedily  recovered.  About 
two  months  afterAvards  the  giddiness  returned,  but  in  a  more  persis- 
tent form,  accompanied  by  double  vision.  He  had  a  foul  tongue, 
palpitation,  and  flatulency  ;  and  there  Avas  a  fixed  pain  in  both  sides 
of  the  forehead  over  the  frontal  sinuses.  The  ordinary  discharge 
from  the  car  continued,  and  the  numb  feeling  in  the  right  arm  re- 
curred, extending  from  the  elboAv  to  the  fingers,  and  folloAving  accu- 
rately the  course  of  the  ulnar  nerve.  At  this  time  he  Avas  treated 
with  blisters  behind  the  ears,  but  Avithout  much  relief.  A  month 
before  the  patient  came  to  me  he  was  under  the  immediate  care  of 
Professor  Miller,  who  stated  that  he  Avas  then  relieved  by  food  and 
stimuli  and  the  administration  of  tonics.  In  a  day  or  two  the  symp- 
toms assumed  a  pericranic  character  ;  they  Avere  also  intermittent, 
affecting  the  left  side  of  the  forehead,  eye,  and  face,  and  were  unac- 
companied by  stuffing  of  the  nostril  on  that  side.  The  treatment 
Avas  then  changed  to  FoAvler's  solution,  Avith  an  anodyne  embroca- 
tion ;  and  in  ten  days  the  pain,  giddiness,  and  uneasy  feelings  in 
the  arm  all  passed  away.  At  the  time  of  my  seeing  him  he  com- 
plained of  occasional  SAvimming  in  the  head,  pain  in  the  ear,  and 
fetid  discharge,  together  Avith  a  sensation  at  the  back  of  the  left  ear 
when  he  walked,  as  if  there  Avere  an  empty  drum  there — a  sensation 
Avhich  Avas  increased  upon  tapping  the  mastoid  process.  The  pain 
extends  over  the  head  from  ear  to  ear,  and  also  over  the  back  part 
of  the  head ;  and  Avhen  the  discharge  is  very  abundant,  he  suffers 
from  the  extreme  sensitiveness  of  a  spot  three  inches  posterior  to 
the  upper  part  of  the  ear.  When  he  presses  upon  the  left  jugular 
vein,  he  feels  a  great  Aveight  at  the  back  of  the  ear,  as  if  something 
would  burst. 

On  inspection,  the  surface  of  the  meatus  Avas  observed  to  be  red 
and  denuded  of  epidermis  ;  the  upper  and  only  visible  part  of  the 
membrana  tympani  Avas  also  red,  and  evidently  fallen  iuAvards  to- 


362  THE    DISEASES     OF    TUE    EAR. 

wards  the  promontory.  The  lower  half  of  the  memhrana  tympani 
was  concealed  by  a  polypus.  The  discharge  was  milky  and  A'ery 
offensive.  Upon  slightly  blowing  the  nose  with  closed  nostrils,  the 
air  passed  through  the  Eustachian  tube  into  the  tympanic  cavity  ; 
but  it  did  not  pass  into  the  meatus  ;  so  that  the  memhrana  tympani 
was  believed  to  be  entire.  The  power  of  hearing  was  so  deterio- 
rated, that  the  watch  was  not  heard  ;  the  crack  of  the  nail  was,  how- 
ever, distinctly  perceived. 

The  diagnosis  formed  by  me  was,  that  there  was  a  collection  of 
pus,  or  of  pus  and  mucus,  in  the  cavity  of  the  mastoid  cells  ;  and 
that,  probably,  the  dura  mater  covering  their  posterior  surface  was 
partially  affected.  I  had  no  doubt  that  the  discharge  from  the 
meatus  was  purely  sympathetic,  and  the  result  of  the  internal  irri- 
tation ;  it  certainly  did  not  come  from  the  seat  of  the  disease. 

Acting  on  this  view  of  the  case,  I  recommended  perfect  quiet, 
tonic  medicines,  and  a  bracing  air ;  while  a  constant  discharge  was 
to  be  kept  up,  first  behind  the  ear,  and  then  between  the  shoulders 
by  means  of  blisters.  This  treatment  producing  but  partial  benefit, 
in  April,  1852,  about  four  months  after  first  seeing  him,  I  ordered  a 
seton  to  be  placed  in  the  nape  of  the  neck.  For  a  time  no  good 
result  followed,  but  in  July  the  fetid  discharge  began  to  dry  up,  the 
power  of  hearing  greatly  improved,  and  the  nervous  energ}-  much 
increased.  During  the  two  years  that  the  seton  has  been  worn,  the 
patient  (to  use  his  own  words)  has  "  enjoyed  a  considerable  measure 
of  health  and  comfort,  and  feels  comparatively  well  and  strong  ;" 
and  he  preaches  regularly  once  a  week.  He  is  annoyed  now  and 
then  by  slight  attacks  of  giddiness,  which  are  supposed,  however, 
to  depend  upon  indigestion  ;  and  are,  he  adds,  "quite  different  from 
the  oppressed  feeling  on  the  brain  which  I  had  two  years  ago." 
Occasionally  the  hearing  is  clogged  for  a  day  or  two,  but  this  state 
gives  way  to  the  use  of  the  syringe  and  warm  water  ;  the  seton 
continues  to  discharge. 

The  above  case  has  been  cited  at  some  length,  because  it  so  fully 
illustrates  the  peculiar  symptoms  of  this  affection  of  the  mastoid 
cells,  which  is  far  from  being  uncommon  ;  and  because  it  shows  the 
decided  benefit  which  is  to  be  obtained  by  counter-irritation  long 
continued. 

Before  concluding  the  subject  of  treatment,  I  will  offer  a  few  ob- 
servations on  the  relation  between  the   presence  of  discharge  from 


THE    MASTOID     CELLS.  363 

the  ear  and  disease  of  the  bone  or  brain.  Patients  sometimes  come 
to  comphiin  of  having  been  objected  to  at  a  Life  Insurance  Office, 
on  account  of  a  long-standing  discharge  from  one  or  both  ears ;  or 
an  opinion  is  requested  whether  such  a  discharge  is  a  valid  cause 
amiinst  insurino;  a  life.  No  doubt  a  discharge  from  the  ear  should 
always  be  regarded  with  suspicion  ;  an  opinion  which  is  borne  out 
by  an  inspection  of  the  following  table,  showing  the  relation  be- 
tween the  duration  of  the  discharge  and  the  acute  symptoms.  The 
cases  are  taken  from  a  paper  of  mine  in  the  3Iedico-Chirurgical 
Transactions  for  1851. 


364 


THE    DISEASES    OP    THE    EAR. 


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THE    MASTOID     CELLS. 


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366  THE     DISEASES     OF    THE     EAR. 

It  is  true  that  many  persons  live  long,  having  had,  during  the 
Avhole  of  life,  a  discharge  from  the  ear  -without  any  disease  of  the 
bone :  others  live  many  years  •with  a  discharge,  but  at  death  the 
bone  and  dura  mater  are  found  affected,  and  might  under  many  cir- 
cumstances have  assumed  an  active  form  of  disease,  ending  in  death. 
It  is  important,  therefore,  to  be  able  to  form  an  opinion  respecting 
cases  of  the  kind.  To  do  this,  it  is  first  necessary  to  decide  upon 
the  source  of  the  discharge.  If  it  arises  from  the  dermoid  meatus, 
the  membrana  tympani  being  entire,  there  is,  as  before  stated,  most 
probably  irritation  in  the  tympanic  cavity  or  mastoid  cells,  of  which 
irritation  the  discharge  is  the  symptom.  Unless  there  •were  simply 
some  eczematous  state  of  the  meatus  to  account  for  the  discharge, 
and  unless  the  hearing  power  Avere  perfect,  such  a  case  should  be 
looked  upon  ■with  suspicion,  especially  if  attended  ■with  any  symptoms 
of  brain  or  cerebral  irritation.  Again,  if  the  discharge  issues  from 
the  tympanic  cavity  through  a  small  or  a  valvular  opening,  and  it 
is  requisite  to  blo^w  the  nose  forcibly  to  clear  out  the  tympanum, 
there  probably  is,  or  ■will  be,  some  affection  of  the  bone,  from  the 
accumulation  of  the  discharge.  If  there  is  a  large  orifice  in  the 
membrana  tympani,  or  that  membrane  is  absent;  if  there  is  no  ulcer- 
ation of  the  mucous  membrane  of  the  tympanum ;  if  there  is  some 
power  of  hearing  remaining ;  and  if  by  pressing  and  tapping  the 
region  round  the  ear,  no  pain  is  felt ;  and  if  there  are  no  other  symp- 
toms of  disease  in  the  ear  or  head,  I  think  it  may  be  assumed  that 
there  is  no  disease  of  the  bone  ;  and  that  by  attention  to  daily 
syringing,  and  the  other  plans  alluded  to  when  speaking  of  the 
treatment  of  these  affections  of  the  ear,  there  is  a  fair  prospect  of 
the  disease  remaining  confined  to  the  mucous  membrane  of  the  ear. 
On  the  other  hand,  it  becomes  a  duty  to  state  that  any  negligence 
on  the  part  of  the  patient,  by  which  the  discharge  should  be  allowed 
to  collect  so  as  to  fill  up  the  orifice  in  the  membrana  tympani — a  blow 
on  the  ear,  an  attack  of  fever,  or  any  severe  illness,  might  cause  an 
irritation  in  the  ear,  which,  if  unattended  to,  might  advance  to  the 
bone. 


CHAPTER    XV. 


THE  DISEASES  OF  THE  NERVOUS  APPARATUS  OF  THE  EAR,  PRO- 
DUCING WHAT  IS  USUALLY  CALLED  "NERVOUS  DEAFNESS." 


.  DISEASES  IN  WHICH  THE  EAR  ALONE  IS  AFFECTED  : — 1.  FROM  COXCUSSIOX — THREE 
MODES — BLOWS  ON  THE  EAR — LOUD  SOUNDS — FALLS.  2.  FROM  THE  APPLICATION  OF 
COLD — COLD  AIR — COLD  WATER.  3.  FROM  THE  EFFECT  OF  MORBID  POISONS — RHEU- 
MATIC    FEVER — TTPHUS    FEVER SCARLET    FEVER  —  MUMPS — GOUT.       h.    DISEASES    IN 

WHICH    THE    BRAIN    AS    WELL    AS     THE     EAR   IS    AFFECTED  : — 1.    MENTAL     EXCITEMENT 

OVER-STUDV — SORROW.       2.  BODILY  DEBILITY WANT    OF    SLEEP — ACCOUCHEMEXTS — 

OVER-EXHAUSTION    IN    HOT    CLIMATES — FASTING — NEURALGIA. 


The  nervous  apparatus  whicli  receives  the  sonorous  undulations 
from  the  tympanum,  and  conveys  them  to  the  brain — one  of  the 
most  delicate  structures  in  the  human  body — is  liable  to  many  func- 
tional and  organic  derangements.'  As  some  cases  of  deafness  depen- 
dent upon  the  derangement  of  the  nervous  apparatus  connected  with 
the  organ  of  hearing,  appear  to  be  caused  by  the  condition  of  the 
brain  generally,  or  of  that  part  in  intimate  relation  with  the  acoustic 
nerve,  it  has  seemed  desirable  to  divide  the  nervous  diseases  of  the 
ear  into  two  classes  :  to  the  first  of  which  belong  those  cases  where 
the  special  nervous  apparatus  of  the  organ  is  alone  affected  ;  to  the 
second.,  those  where  the  brain  conjointly  with  the  ear,  seems  to  be 
injured. 

The  first  class  may  be  subdivided  into  diseases  arising  from — 

(1.)   Concussion. 

(2.)  The  application  of  cold'. 

(3.)  Various  poisons  :  as  that  of  typhus,  scarlet,  or  rheumatic 
fevers,  of  measles  and  mumps,  of  gout,  of  an  accumulation  of  bile 
in  the  blood,  and  of  quinine  in  large  doses. 

And  the  secondanto  diseases  arising  from — 

'  As  I  have  nothing  to  add  to  the  descriptions  usually  given  of  the  anatomy  of  the  laby- 
rinth, I  have  not  entered  upon  the  subject. 


368  THE     DISEASES     OF     THE     EAR. 

(1.)  Excess  of  mental  excitement. 
(2.)  Physical  debility. 


[a.)    DISEASES    IN    AVIIICH    THE    EAR    ALONE    IS    AFFECTED. 

This  section  will  be  occupied  with  a  revicAv  of  the  various  kinds 
of  disease  comprehended  under  the  first  of  the  above  classes,  all  of 
which  are  usually  accompanied  by  more  or  less  of  congestion. 


(1.)  I>chHit>j  of  the  JVervous  Apparatus  of  the  Ear  2)rodueed  hy 
Concussion. 

Concussion  may  arise  in  three  ways  ;  either  from  a  blow  on  the 
ear,  or  from  the  effect  of  loud  sounds,  or  from  a  jar  of  the  whole 
frame.  Affections  of  the  nervous  apparatus  of  the  ear,  as  the 
result  of  blows  on  the  external  organs,  are  not  very  common,  !?ince, 
as  a  general  rule,  the  membrana  tympani  gives  way  and  is  ruptured, 
and  consequently  the  shock  on  the  drum  is  so  far  modified  in  its 
effect  on  the  ossicles  and  the  fenestra  ovalis,  that  the  contents  of 
the  labyrinth  receive  no  greater  injury  than  that  which  causes  a 
slight  dulness  of  hearing  for  a  few  days. 

Cases  of  more  permanent  injury  to  the  acoustic  nervous  apparatus 
do,  however,  sometimes  happen  from  the  effects  of  a  blow  on  the  ear, 
as  in  the  following  case. 

Injury  to  the  nervous  apparatus  of  the  ear,  produced  by  a  hloiv  on 
that  organ. — A  physician  in  London,  while  playing  with  his  little  chil- 
dren, suddenly  brought  his  right  ear  in  contact  with  the  head  of 
one  of  them,  causing  a  rather  severe  concussion  on  that  side  of  his 
own  head.  The  concussion  was  instantly  followed  by  a  singing  in 
the  ears.  I  saw  the  patient  soon  after  the  accident,  but  could 
detect  no  unnatural  appearance  in  the  membrana  tymj»ani  ;  and  on 
carefully  testing  the  hearing  power  by  the  watch,  there  appeared  to 
be  no  dulness  of  hearing.  This  physician  has  been  seen  by  me  from 
time  to  time  since  the  accident,  and  he  tells  me  the  singing  remains 
as  it  was  on  the  day  the  concussion  took  place. 

The  nervous  apparatus  of  the  ear  is  frequently  injured  also  from 
the  effect  of  a  general  concussion  of  the  body,  in  which  case  the 
hearing   power   is  often  entirely  destroyed.       The  well   known  in- 


NERVOUS    DEAFNESS.  369 

stance  of  the  late  Dr.  Kitto,  wlio  Avas  rendered  wholly  deaf  by  a 
fall  from  the  top  of  a  house  when  a  boy,  may  be  noticed  in  illustra- 
tion, and  some  others  follow  which  have  fallen  under  my  own  obser- 
vation. 

Fatal  deafness  in  the  rigid  ear,  and  partial  deafness  in  the  left, 
folloiving  a  fall  from  a  horse. — The  Rev.  R.  F.,  aged  53.  During 
many  years  his  hearing  has  been  dull  during  a  cold.  Five  years 
before  seeing  me,  he  had  a  fall  from  his  horse,  and  the  fall  was  fol- 
lowed by  a  discharge  of  blood  from  the  right  ear  for  the  space  of 
tAvo  days,  and  subsequently  of  matter.  For  some  days  after  the 
accident,  the  air  whistled  out  of  his  right  ear  whenever  the  nose  was 
blown.  Since  the  accident,  the  right  ear  has  been  entirely  useless, 
and  the  left  so  deaf  that  he  has  to  be  loudly  addressed  within  a 
yard  of  that  ear.  There  has  also  remained  a  constant  singing  noise 
in  the  head.  On  inspection,  the  hearing  of  the  7'ight  car  was  found 
to  have  been  wholly  destroyed,  and  the  membrana  tympani  pre- 
sented an  orifice,  the  margins  of  Avhich  were  opaque  and  uneven. 
Left  ear. — The  membrana  tympani  was  dull  on  its  surface,  and  in 
parts  calcareous. 

In  some  instances,  slight  amelioration  of  the  deafness  following 
the  accident  takes  place,  as  in  the  next  case. 

Total  deafness  in  the  right  ear  folJoioing  a  fall  from  a  phaeton  ; 
gradual  improvement. — The  Rev.  J.  L.,  aged  35,  had  a  deafness  in 
the  right  ear  during  a  cold  four  years  ago.  In  the  same  year  he 
fell  from  a  phaeton,  and  was  unconscious  for  some  days.  When  he 
recovered  his  sensibility,  he  found  that  there  was  a  hissing  sound,, 
like  that  from  a  teakettle,  in  the  right  ear,  which  Avas  completely 
deaf.  During  two  years,  however,  subsequent  to  the  accident,  the 
power  of  hearing  gradually  improved,  so  that  the  patient  is  able  to 
hear  a  loud  voice  Avith  that  ear.  The  noises  still  continue,  and  are 
aggravated  by  wine,  or  by  bodily  or  mental  fatigue  ;  when  writing 
or  studying,  these  noises  become  overpoAvering,  but  in  the  morning 
are  much  lessened.  On  inspecting  the  right  ear,  the  air  is  distinctly 
heard  by  me  to  enter  the  tympanic  caA'ity,  but  the  patient  experi- 
ences no  sensation  in  the  ear  Avhen  it  enters.  A  loud  ticking  watch 
is  heard.  When  spoken  to  through  a  trumpet,  loudly  and  slowly, 
the  voice  is  heard,  but  not  till  a  second  or  two  after  the  Avord  has 
been  uttered.     The  membrana  tympani  Avas  opaque. 

The  violent  shock  communicated  to  the  nervous  system  of  the  ear 
(most  probably  through  the  medium  of  the  membrana  fenestras  ro- 

24 


370  THE     DISEASES     OF    THE     EAR. 

tiindio)  in  the  act  of  coughing,  sometimes  produces  deafness ;  in- 
deed, in  some  cases,  hooping-cough  seems  rather  to  cause  deafness 
by  this  means  than  by  the  agency  of  poison. 

Nervous  system  of  the  ear  injured  by  violent  coughing. — Mrs.  A. 
consulted  me  in  1851,  and  stated  that  a  week  previous  to  her  visit, 
directly  after  coughing,  she  experienced  a  pain  in  the  left  ear,  which 
lasted  for  two  hours,  together  with  a  loud  singing  noise  which  has 
never  ceased.  She  complains  of  an  unpleasant  sensation  as  if 
sounds  passed  through  the  ear,  and  is  troubled  with  a  sense  of  giddi- 
ness, and  a  feeling  of  confusion  in  the  head.  Every  step  she  takes 
sounds  like  the  beating  of  a  drum.  Tlie  mcmbrana  tympani  was 
fallen  in,  and  its  surface  dull.  The  watch  was  heard  only  when  in 
contact  with  the  ear.  Means  having  been  used  to  diminish  the  con- 
gestion of  the  nervous  apparatus  of  the  ear,  the  distressing  symp- 
toms of  nervousness  and  giddiness  disappeared,  but  the  singing 
sounds  remained. 

The  concussion  upon  the  nervous  system  of  the  ear  resulting  from 
loud  sounds  is  a  very  common  cause  of  deafness.  In  a  previous  part 
of  this  volume,  when  speaking  of  the  functions  of  the  ossicles  and 
muscles  of  the  tympanum,  it  was  shoAvn  tliat  the  one  use  of  the 
tensor  tympani  muscle  is  to  render  tense  the  membrane  of  the 
fenestra  rotunda,  as  well  as  that  of  the  larger  membrane ;  and  in 
this  tense  condition  the  membrane  of  the  fenestra  rotunda  is  thrown 
into  vibratory  movements  of  much  less  extent  than  when  it  is  in  a 
relaxed  state.  When  a  loud  sound  is  anticipated,  the  tensor  tym- 
pani muscle  draws  the  membrana  tympani  and  the  membrana  fenes- 
trae  rotundne  tense ;  so  that,  when  the  approach  of  a  loud  sound  is 
expected,  it  rarely  injures  the  ear.  On  the  contrary,  however,  when 
both  membranes  are  comparatively  lax,  the  same  sounds  throw  them 
into  very  extended  vibrations,  and  tlic  fluid  in  the  cochlea  by  the 
magnified  movements  of  the  membrana  fenestrjx:  rotundi\j  is  so  con- 
cussed as  to  injure,  and  often  most  seriously,  the  expansion  of  the 
auditory  nerve  in  the  laliyrinth. 

Injury  to  the  nervous  apparatus  of  the  ear  may  be  produced  by  a 
variety  of  sounds.  Cases  Jiave  been  seen  by  me  in  which  a  cannon- 
ade at  laud  or  sea,  or  the  firing  a  single  cannon,  has  produced  the 
injury;  and  others  have  occurred  where  an  explosion  of  gas,  thunder, 
a  pistol  shot,  or  even  loud  shouting  near  the  ear,  have  resulted  in 
the  same  effect ;  but  the  most  common  cases  are  those  which  follow 
the  long-continued  sport  of  shooting,  where  the  deafness  almost  in- 


NERVOUS    DEAFNESS.  371 

variably  occurs  in  the  left  ear,  which  is  turned  towards  the  gun 
during  its  explosion,  and  consequently  receives  the  direct  concussion. 

The  treatment  in  recent  cases  when  the  patient  is  suffering  from 
the  immediate  effect  of  the  shock,  consists  in  the  removal  of  the  con- 
gestion by  the  application  of  leeches,  or  by  cupping  :  by  the  admi- 
nistration of  mild  aperients ;  by  strengthening  the  general  nervous 
system  as  much  as  possible,  and  by  securing  the  ear  against  the 
effect  of  loud  sounds. 

Noises  in  the  ears,  deafness,  and  a  feeling  of  deadness  in  the  head, 
following  the  sound  of  a  pistol  shot;  relief. — Mr.  C.  S.,  aged  45,  a 
fortnight  before  consulting  me,  fired  a  pistol,  for  the  first  time  in  his 
life,  in  the  open  air  on  a  cold  frosty  day.  The  concussion  was  in- 
stantaneously followed  by  a  hissing  noise  in  each  ear,  but  more  espe- 
cially in  the  right,  and  he  also  felt  a  shock  throughout  the  whole  of 
the  head,  followed  by  a  "  feeling  of  deadness"  in  it.  Since  the  acci- 
dent, he  has  been  dull  of  hearing,  and  has  observed,  among  other 
things,  that  he  could  not  hear  the  "  ring  of  money."  Leeches  and 
mustard  plasters  were  applied  behind  the  ears,  and  small  doses  of 
calomel  and  colocynth  were  administered.  Immediate  relief  to  the 
head  and  ears  followed  the  application  of  the  leeches,  and  in  a  week 
the  hearing  had  improved,  and  the  noises  diminished. 

Nervous  apparatus  injured  hy  the  report  of  a  cannon. — ^Y.  L.  C, 
Esq.,  aged  73,  about  four  months  before  consulting  me,  his  hearing 
being  then  perfect,  was  sitting  in  the  open  air  at  Brighton,  looking 
upon  the  sea,  when  a  cannon  near  where  he  sat  was  fired,  without 
his  having  any  idea  of  such  a  proceeding  being  about  to  take  place. 
The  concussion  was  immediately  followed  by  a  singing  in  the  ears, 
or  rather  about  two  yards  from  them,  and  a  sensation  as  if  water 
were  rushing  through  them.  Since  the  accident,  he  has  heard  a 
whisper  very  distinctly,  but  a  loud  voice  causes  unpleasant  jarring 
sensations  in  the  ears,  and  deafness  to  all  sounds.  In  another  case, 
the  ear  was  "benumbed"  for  some  time  after  the  patient's  child  had 
shouted  into  it. 

Nervous  apparatus  of  the  ear  injured  by  very  loud  shouting  ;  very 
distressing  noises  ;  great  relief. — When  surgeon  to  the  St.  George's 
and  St.  James's  Dispensary,  a  poor  man  applied  to  me  for  relief 
from  deafness  and  very  distressing  noises  in  the  left  ear.  The 
latter  had  lasted  several  years,  and  the  patient,  a  strong  muscular 
man,  thinks  they  were  caused  by  the  loud  shouting  he  is  obliged  to 


372  THE     DISEASES    OF    THE     EAR. 

practice  as  a  hawker  of  fish.  These  noises  came  on  in  the  left  ear, 
and  after  remaining  there  some  time  advanced  to  the  left  side  of 
the  head ;  they  have  increased  lately,  sometimes  resembling  "  a 
rapid  tinkling,"  at  others  being  like  the  driving  of  a  sledge  ham- 
mer ;  but  most  commonly  they  resemble  the  roaring  of  the  sea. 
When  at  their  loudest,  as  after  exertion,  the  house  seems  to  go 
round  with  him.  The  ear  is  quite  insensible  to  any  sound  but  that 
of  these  noises.  The  right  ear  is  healthy.  On  examination,  the 
membrana  tympani  of  the  affected  ear  "vvas  found  to  be  opaque,  and 
the  air  passed  through  the  Eustachian  tube  Mith  a  loud  crackling. 
As  this  was  a  local  affection,  as  the  patient  was  a  strong  man,  and 
as  the  symptoms  were  increased  by  any  cause  which  increased  a  flow 
of  blood  to  the  organ,  I  determined  to  treat  the  case  as  one  of  con- 
gestion, and  accordingly  ordered  the  patient  to  apply  twelve  leeches 
below  the  ear,  followed  by  a  cantharidine  cerate  dressed  with  ungu- 
entum  hydrargyra,  at  the  same  time  that  the  outer  half  of  the 
meatus  was  washed  with  a  solution  of  nitrate  of  silver  suflBciently 
strong  to  produce  desquamation.  This  was  followed  by  the  use  of 
a  solution  of  chloride  of  zinc  (six  grains  to  the  ounce)  to  the  mea- 
tus, so  as  to  cause  a  discharge.  The  result  of  this  treatment  was 
satisfactory.  The  noises,  the  patient  says,  "  have  not  been  so  loud 
or  nearly  like  it :"  and  ten  days  subsequently  to  this  report,  he 
said  that  his  head  was  much  better,  and  "  he  could  do  his  work  with- 
out being  obliged  to  give  up." 

Nervous  apparatus  of  the  ear  injured  by  the  explosion  of  bladders 
of  gas. — J.  B.,  aged  64,  was  admitted  under  my  care  at  St.  Mary's 
Hospital  in  1853.  He  stated  that  nine  months  previously,  directly 
after  the  explosion  of  two  bladders  of  gas  at  the  distance  of  a  yard 
from  his  head,  he  suddenly  became  so  hard  of  hearing,  that  he  could 
not  hear  a  voice  except  when  spoken  to  distinctly  at  a  distance  of 
two  yards  from  the  head.  The  explosion  was  followed  by  a  singing 
sound  in  the  ears,  which  gradually  subsided.  The  watch  could  not 
be  heard  at  a  distance  of  more  than  two  inches  from  the  right  ear, 
and  only  when  in  contact  with  the  left.  The  treatment  consisted  in 
the  application  of  leeches. below  the  ears,  but  the  patient  did  not 
return  to  report  progress. 

The  following  is  a  well-marked  case  in  which  the  nervous  appa- 
ratus was  injured  by  shooting. 

Deafness  in  the  left  ear  following  shooting,  and  temporarily  in- 
creased by  a  days  sport. — F.    F.,  Esq.,  aged  23,  accustomed  to 


NERVOUS    DEAFNESS.  373 

shoot,  has  been  gradually  becoming  dull  in  the  left  ear.  For  two 
years  he  has  not  been  able  to  hear  general  conversation  distinctly, 
and  the  striking  of  the  clock  seems  no  longer  attended  by  the  natural 
sound.  Is  more  dull  of  hearing  during  a  cold.  Is  not  aware  of 
any  cause  that  could  have  produced  the  deafness.  The  right  ear 
was  in  a  natui-al  state ;  by  the  left  the  watch  was  only  heard  at  the 
distance  of  half  an  inch.  The  treatment  consisted  in  the  use  of 
gentle  counter-irritants  over  and  around  the  ear,  and  in  doing  all 
that  could  be  suggested  for  diminishing  local  and  general  conges- 
tion. This  treatment  was  followed  by  great  improvement  at  the  end 
of  about  three  weeks,  when  the  watch  could  be  heard  at  a  distance 
of  four  inches — an  improvement  which  continued,  with  the  excep- 
tion of  a  considerably  increased  amount  of  deafness  which  ensued 
upon  a  morning's  shooting.  This  increased  deafness  continued  for 
some  days,  and  then  gradually  diminished.  The  last  time  the  patient 
was  seen  by  me,  the  hearing  had  not  regained  the  previously  im- 
proved state,  for  the  watch  could  only  be  heard  in  contact  with  the 
ear. 

Not  having  had  the  opportunity  of  ascertaining  the  condition  of 
the  ear  by  the  aid  of  dissection,  I  have  assumed  that  in  these  cases, 
arising  from  shooting,  the  nervous  system  of  the  ear  is  defective. 
The  grounds  of  this  conclusion  are,  that  the  noises  and  defective 
hearing  followed  immediately  on  the  concussion,  and  all  the  symp- 
toms indicated  that  a  shock  had  been  given  to  the  nervous  system. 
The  secondary  effect  of  this  concussion,  it  can  scarcely  be  doubted, 
may  be  anchylosis  of  the  stapes  to  the  fenestra  ovalis.  In  cases, 
indeed,  when  the  nervous  system  of  the  ear  has  received  a  very 
severe  concussion,  and  deafness  has  subsequently  slowly  come  on,  I 
have  convinced  myself  of  this  anchylosis  by  dissection,  and  will 
now  relate  one  or  two  cases  of  the  kind. 

Concussion  of  the  nervous  apparatus  of  the  car  hy  thunder ;  com- 
plete deafness. — T.  D.,  aged  80,  is  so  completely  deaf  that  he  can- 
not hear  any  sound.  He  states  that,  fifteen  years  ago,  when  in  a 
thunder-storm  on  the  coast  of  Guinea,  he  was  rendered  thoroughly 
deaf  by  a  clap  of  thunder,  and  since  then  has  not  heard  a  sound. 
On  examination,  an  orifice  was  observed  in  each  membrana  tym- 
pani.  No  treatment  was  attempted,  but  about  two  years  after  the 
examination,  the  opportunity  was  given  me  of  dissecting  his  ears, 
which  were  in  the  following  morbid  condition. 

lUght  ear. — At  the  posterior  part  of  the  membrana  tympani  was 


374  THE    DISEASES    OF    THE     EAR. 

an  orifice  about  two  lines  in  diameter,  the  remaining  portion  of  tlie 
membrane  being  white,  thick,  and  tense,  and  more  concave  exter- 
nally than  natural :  parts  were  also  calcareous.  In  the  centre  of 
the  remnant  of  the  membrana  tympani  is  a  space  about  lialf  a  line 
in  diameter,  in  Avhich  the  epidermoid,  dermoid,  and  nmcous  layers 
alone  remain.  The  long  process  of  the  incus  and  the  crura  of  the 
stapes  are  gone,  and  the  expanded  base  of  the  stapes  is  attached  to 
the  fenestra  ovalis  more  firmly  than  natural.  The  membranous 
labyrinth  was  atrophied,  and  the  nervous  fibrillte  of  the  cochlea 
appeared  the  same. 

Left  ear. — Like  the  right ;  except  that  the  crura  of  the  stapes 
were  only  partially  absorbed. 

In  another  case  of  total  deafness  produced  by  a  loud  cannonading, 
the  only  morbid  condition  that  could  be  detected  by  me,  on  dissec- 
tion, was  that  the  otoconie  was  more  abundant  than  natural,  while 
in  the  vestibule  there  was  a  deposit  of  oval-shaped  cells. 

Results  similar  to  those  noticed  as  following  the  practice  of  shoot- 
ing, also  occur  to  operatives  engaged  in  occupations  involving  very 
loud  sounds.  Thus  in  a  large  factory  for  making  steam-boilers,  I 
found  a  great  number  of  men  engaged  in  riveting  the  bolts,  and 
therefore  obliged  to  work  inside  the  boiler,  who  were  very  deaf.  It 
will  be  very  interesting  to  ascertain  by  post-mortem  inspection  the 
pathological  condition  of  the  ear  when  subjected  to  such  loud 
sounds,  and  some  day  perhaps  the  opportunity  will  be  afforded  me 
of  doing  so. 


(2.)   The  effect  of  the  application  of  cold  on  the  nervous  apparatus 

of  the  ear. 

There  are  two  classes  of  cases  in  Avhich  a  diminution  of  the  tem- 
perature is  found  to  be  injurious  to  the  ear  :  in  the  one  cold  air,  in 
the  other  cold  water,  is  the  agent  producing  the  effect.  I  have 
known  engine-drivers  to  suff'er  from  deafness  after  being  exposed  to 
a  cold  blast,  and  huntsmen  also  who  have  had  a  sudden  "  check" 
when  very  hot,  and  have  then  stood  about  while  a  bitter  east  wind 
was  blowing  upon  them.  The  effect  of  the  application  of  cold 
seems,  in  the  first  instance,  to  produce  congestion  ;  and  then  to 
lead  to  the  symptoms  of  noise  in  the  ear  and  of  deafness,  which 
appear  to  depend  upon  a  depressed  or  depraved  action,  subsequent 


NERVOUS     DEAFNESS.  375 

to  and  resulting  from  the  congestion.  In  what  the  depraved  action 
consists,  it  is,  however,  difficult  to  determine.  The  congestion  often 
yields  to  the  application  of  leeches  ;  and  the  depraved  action  is  fre- 
quently diminished,  sometimes  wholly  removed,  by  the  use  of  gentle 
counter-irritants,  tonics,  shower-baths,  &c. 

The  first  series  of  cases  consists  of  those  in  wliich  the  injury  fol- 
lowed exposure  to  cold  air. 

Total  deafness  in  both  ears  following  exposure  to  cold  hy  sleeping 
in  the  open  air. — A  farm-laborer,  aged  28,  Avas  admitted  under  my 
care  at  the  St.  George's  and  St.  James's  Dispensary,  in  June,  1850, 
on  account  of  complete  deafness  in  both  ears.  He  said  that  eighteen 
months  previously,  after  sleeping  in  an  open  cart  in  which  he  was 
riding  in  the  winter,  a  usual  practice  with  him,  intense  pain  came 
on  between  the  right  temple  and  ear,  Avhich  was  relieved  by  the  use 
of  veratrine  ointment.  About  three  weeks  after  the  exposure  to 
cold  the  deafness  made  its  appearance,  at  first  for  a  day  or  two 
only,  and  then  disappeared  :  in  the  course  of  a  few  days,  however, 
it  recurred  with  increasing  intensity  and  once  more  disappeared. 
This  recurrence  and  disappearance  of  the  deafness  ended  after  a  few 
more  days  in  total  and  permanent  loss  of  hearing.  At  the  present 
time  he  cannot  hear  a  gun,  even  if  fired  close  to  the  head.  He 
complains  of  loud  noises  in  the  hfead,  and  of  great  heaviness  and 
sleepiness.  All  kinds  of  empirical  treatment  had  been  tried  on 
him  ;  oils  of  various  kinds  had  been  dropped  into  the  ears,  Avith 
brandy  and  salt,  and  then  hot  baked  salt  behind  them  ;  every 
species  of  medicine  had  been  given,  and  he  had  been  cupped  and 
blistered  at  the  nape  of  the  neck,  but  without  producing  any  good 
effect.  On  examination,  the  upper  part  of  each  membrana  tympani 
was  found  to  be  red,  the  lower  part  being  concave  and  white  ;  air 
entered  through  the  Eustachian  tube  and  caused  a  loud  crackino; 
sound.  Some  relief  to  the  head-symptoms  followed  a  discharge 
from  each  meatus,  which  was  kept  up  by  the  application  from  time 
to  time  of  the  chloride  of  zinc. 

Deafness  and  singing  in  the  ears  following  exposure  to  cold  while 
skating. — J.  V.,  Esq.,  aged  49,  consulted  me  in  March,  1852.  His 
health  was  good,  and  his  constitution  strong.  He  stated  that  twelve 
or  fourteen  years  previously,  while  skating  on  a  bitterly  cold  day,  a 
singing  sound  suddenly  came  on  in  the  left  ear,  which  has  remained 
ever  since ;  being  at  times  very  loud,  and  then  much  subdued.  A 
few  years  after  this  exposure,  the  left  ear  became  gradually  dull  of 


376  THE     DISEASES      OF    THE    EAR. 

hearinff,  and  receutlv  Lotli  the  sin";infi  and  dulness  of  hearing  have  in- 
creased.  The  power  of  hearing  varies,  but  is  not  worse  after  fatigue 
or  excitement.  With  the  right  ear  the  hearing  distance  was  three 
inches  ;  with  the  left,  half  an  inch  only.  Two  leeches  were  ordered 
to  be  applied  below  each  ear,  and  the  ears  to  be  syringed  with  warm 
water,  the  object  being  to  remove  congestion.  This  treatment  was 
followed  by  relief;  but  with  the  further  progress  of  the  case  I  am 
unacquainted. 

Two  other  cases  of  injury  produced  by  the  application  of  cold  air 
to  the  ear  may  be  briefly  alluded  to.  The  first  was  that  of  a  gentle- 
man, aged  21,  who  ten  months  before  my  seeing  him,  being  exposed 
to  a  very  cold  February  wind  blowing  in  the  left  ear,  had  a  singing 
and  pulsation  ensue  within  that  organ  ;  these  sensations  are  unaccom- 
panied Avith  deafness,  and  are  worse  while  in  bed  or  reading.  At 
times  they  wholly  disappear.  The  second  case  is  that  of  a  clergy- 
man, aged  ^^^  who  having  been  exposed  to  cold  in  a  railway  car- 
riage, three  years  before  my  seeing  him,  was  subsequently  attacked 
by  a  whizzing  sound  in  the  left  ear,  which  has  never  ceased.  By 
sitting  up  late  at  night,  or  by  entering  a  warm  room  from  the  cold 
air,  the  sound  is  increased,  but  is  better  rather  than  worse  after 
dinner.  Complains  of  dulness  of  hearing,  as  general  conversation 
is  not  heard. 

The  following  are  cases  whore  the  application  of  cold  Avater  re- 
sulted in  injury  to  the  ear : — 

Deafness  foUoicing  bathing  in  cold  water. — T.  F.,  aged  ll>,  saAv 
me  on  account  of  his  deafness.  He  said,  that  more  than  a  year  pre- 
viously deafness  came  on  sloAvly,  after  bathing  daily  in  cold  fresh 
Avater,  and  in  a  month  or  six  Aveeks  he  became  as  deaf  as  at  present. 
The  affection  has  been  stationary  for  some  months.  He  requires 
speaking  to  loudly__Avitliin  the  distance  of  a  yard,  and  at  times  suffers 
from  a  buzzing  in  the  ears.  He  is  not  deafer  during  a  cold,  and 
docs  not  hear  better  in  a  carriage.  The  right  ear  is  rather  Avorse 
than  the  left.  The  previous  treatment  consisted  in  dropping  oils 
into  the  ears,  and  in  syringing  them  Avith  Avarm  Avater.  In  each  ear 
the  Avatch  Avas  heard  only  Avhen  in  contact.  The  mombrana  tympani 
appeared  to  be  slightly  more  concave  than  natural,  and  its  surface 
Avas  dull  and  congested.  The  treatment  consisted  in  the  application 
of  a  vesicating  paper  behind  each  ear,  and  in  taking  small  doses  of 
blue-pill  and  iodide  of  potassium,  a  treatment  Avhich  Avas  followed  by 
a  slight  amelioration  of  the  symptoms. 


NERVOUS     DEAFNESS.  377 

Deafness  produced  in  two  days  by  dipping  the  head  in  cold  water. 
— A  girl,  aged  14,  the  daughter  of  a  farmer  consulted  mc  in  1853. 
She  stated,  that  two  years  previously^  when  very  much  heated,  she 
plunged  her  head  into  cold  water,  and  two  days  afterwards  became 
so  deaf  that  she  required  to  be  loudly  spoken  to  close  to  the  head. 
The  deafness  varies  slightly,  being  worse  during  a  cold,  and  at  times, 
from  no  assignable  cause,  better.  The  treatment  consisted  in  keep- 
ing up  a  slight  discharge  from  the  surface  of  each  mastoid  process, 
and  in  giving  small  doses  of  the  bichloride  of  mercury  (one-thirtieth 
of  a  grain)  with  gentian,  daily.  The  treatment,  pursued  during  two 
months,  resulted  in  decided  improvement. 

Deafness  and  noises  in  the  ears  after  bathing. — A  man,  aged  29, 
was  admitted  under  my  care  at  St.  Mary's  Hospital,  in  July,  1853. 
He  said,  that  six  years  before,  after  bathing  in  a  canal  of  cold  fresh 
water,  he  became  rapidly  deaf  in  both  ears,  and  in  the  course  of  a 
week  was  so  deaf  as  to  require  to  be  distinctly  spoken  to  quite  close 
to  him  ;  complained  from  the  first  of  buzzing  noises  and  pulsations. 
The  deafness  and  the  noises  increase  in  damp  weather,  or  when  he  is 
tired ;  and  he  also  hears  worse  in  a  carriage  and  amid  loud  sounds. 
The  treatment  consisted  in  the  application  of  gentle  counter-irritants 
over  each  mastoid  process,  and  in  taking  alteratives,  but  without  any 
beneficial  effect. 

(3.)  Deafness  produced  by  the  action  of  morbid  poisons  on  the 
7iervous  apparatus  of  the  ear. 

As  has  been  stated,  in  addition  to  the  causes  just  detailed,  the 
nervous  apparatus  of  the  ear  often  suffers  from  the  action  of  the 
poisons  of  gout,  typhus  fever,  scarlatina,  measles,  or  mumps.  Though 
unable  to  furnish  any  information  of  the  modus  operandi  of  the 
several  poisons  enumerated,  in  some  cases  where  the  functions  of  the 
organ  have  been  wholly  destroyed,  the  nervous  apparatus  of  the  ear, 
on  dissection,  has  been  found  by  me  completely  disorganized,  and 
the  fluid  in  the  cochlea  and  vestibule  dark-colored,  and  occasionally 
tinged  with  blood.  Many  of  the  cases  of  acquired  deaf-dumbness 
originate  in  the  effect  of  poisons  of  various  kinds.  A  careful  con- 
sideration of  the  symptoms  attendant  upon  these  cases,  and  the  re- 
sults of  treatment,  indicate  that  whatever  may  be  the  immediate 
effect  of  the  poison  on  the  nervous  tissue,  the  secondary  effect  is  to 
produce  congestion  of  that  tissue. 


378  THE     DISEASES    OF    THE     EAR. 

Noises  and  deafness  after  rheumatic  fever. — Miss.  B.,  aged  36, 
consulted  me  in  1851.  She  stated,  that  ten  years  previously  she 
had  an  attack  of  rheumatic  fever,  which  "svas  followed  by  dulness  of 
hearing  in  the  right  ear,  and  accompanied  by  a  constant  whizzing 
sound  and  a  pulsation  which  extended  over  the  head.  The  left  ear 
has  lately  become  dull.  The  watch  was  heard  only  when  pressed 
upon  the  right  ear,  or  at  a  distance  of  six  inches  from  the  left. 
Neither  ear  presented  any  appearance  of  disease,  except  a  slight 
dulness  of  the  surface  of  the  left  membrana  tympani.  The  treat- 
ment consisted  in  applying  mustard  plasters  and  stimulating  lini- 
ments to  the  nape  of  the  neck,  and  the  etherial  solution  of  cantha- 
rides  behind  the  ears.  The  result  of  two  months'  perseverance  was 
such  an  improvement  of  the  hearing  power,  that  conversation  could 
be  more  distinctly  perceived,  and  the  watch  could  be  heard  at  half 
an  inch  from  the  right  ear. 

Totid  deafness  foUou'ing  an  attack  of  rheumatic  fever. — ^Ir.  M. 
G.,  aged  17,  a  year  and  a  quarter  before  consulting  me,  had  a  bad 
attack  of  rheumatic  fever,  which  was  followed  by  noises  in  both  ears 
and  gradually  increasing  deafness,  so  that  in  a  month  after  the  fever 
he  could  not  hear  any  sounds.  Since  the  attack,  has  now  and  then 
heard  loud  sounds  for  a  very  short  time :  but  when  he  saw  me  he 
was  so  deaf  that  he  could  not  hear  anything,  even  when  the  poker 
and  tonfrs  were  knocked  ao^ainst  each  other.     The  ears  had  been 

o  o 

syringed,  blistered,  and  galvanized  without  any  effect.  There  was 
no  appearance  of  disease  in  either  ear.  The  case  was  at  once  re- 
garded by  me  as  incurable. 

Partial  deafness  folloiving  an  attack  of  typhus  fever. — Miss  A. 
M.,  aged  16,  saw  me  on  March  1st,  1851.  Eleven  years  previously 
she  had  an  attack  of  typhus  fever,  and  during  the  illness  became  so 
deaf  as  not  to  be  able  to  hear  the  human  voice.  After  the  symp- 
toms of  fever  had  disappeared,  the  power  of  hearing  slowly  returned, 
until  she  was  able  to  hear  when  loudly  spoken  to  close  to  the  head. 
There  was  no  appearance  of  disease  in  either  ear. 

Partial  deafness  folloiving  fever. — V.  A.,  Esq.,  aged  40,  consulted 
me  in  December,  1853.  Twenty  years  before,  he  had  an  attack  of 
fever,  during  and  for  some  time  after  which  he  was  so  deaf  as  to 
re(jnire  to  be  spoken  to  close  to  the  car.  The  hearing  gradually 
returned,  and  at  the  end  of  two  years  he  heard  perfectly  well  for  a 
very  short  time,  when  the  deafness  as  gradually  returning,  he  soon 
had  to  be  loudly  spoken  to  within  a  yard  of  the  head.     Does  not 


NERVOUS     DEAFNESS.  379 

now  complain  of  noises,  but  lias  had  a  ticking  sound  in  the  ears. 
The  deafness  is  worse  after  flurry,  excitement,  or  fatigue,  after 
dinner,  wine  or  beer ;  a  single  glass  of  either  of  the  latter  increases 
the  deafness  instantaneously.  Is  better  after  a  discharge  from  the 
nose,  and  while  riding  in  a  carriage.  The  hearing  power  of  the  left 
ear  is  gone.  On  examination,  no  unnatural  appearance  was  detected 
in  either  ear,  and  the  watch  was  heard  when  pressed  upon  the  right 
ear. 

Total  deafness  foUowing  an  attack  of  fever. — Miss  C.  J.,  aged 
21,  when  a  child  had  an  attack  of  fever,  since  which  time  she  has 
gradually  become  deaf,  and  at  the  present  Mioment  cannot  hear 
even  a  loud  clapping  of  the  hands.  Five  years  ago  both  tonsils 
Avere  partially  removed,  and  tlieir  remnants  have  recently  been 
snipped,  with  no  effect  except  that  of  producing  great  mental  de- 
pression. There  was  no  appearance  of  disease  in  any  part  of  the 
organ. 

The  poison  oi  scarlet  fever,  like  that  of  typhus,  sometimes  injures 
the  nervous  apparatus  of  the  ear,  and  not  unfrequently  complete 
deafness  is  the  result.     The  following  are  illustrative  cases. 

Didness  of  hearing  folloiving  an  attack  of  scarlet  fever. — Mrs.  S., 
aged  26,  had  an  attack  of  scarlet  fever,  eight  years  previous  to 
consulting  me,  and  since  that  time  has  been  troubled  with  a  dul- 
ness  of  hearing,  especially  during  a  cold.  A  year  ago,  after  having 
suffered  much  trouble,  and  after  being  in  weakly  health,  the  power  of 
hearing  gradually  decreased,  and  this  decline  Avas  accompanied  for 
the  first  time  by  pain,  with  irritation  and  discharge  in  both  ears, 
together  with  constant  noises  like  the  bloAving  of  bellows.  Is  un- 
able to  hear  general  conversation,  but  a  single  voice  is  heard  dis- 
tinctly. The  left  ear  is  worse  than  the  right.  On  examination  of 
the  right  ear,  the  surface  of  the  meatus  was  found  to  be  dry  and  to 
contain  small  portions  of  epidermis  ;  the  membrana  tympani  was 
opaque,  and  the  Eustachian  tube  pervious.  The  left  car  was  in  a 
similar  condition. 

Complete  deafness  in  the  right  ear  p>roduced  by  the  p)oison  of 
scarlet  fever. — Mr.  H.,  aged  20,  had  an  attack  of  scarlet  fever  at 
four  years  of  age,  since  which  time  the  right  ear  has  been  so  deaf 
as  not  to  be  able  to  hear  even  the  slightest  sound.  On  examina- 
tion, the  right  membrana  tympani  was  observed  to  be  more  opaque 
than  natural,  and  the  left  ear  was  perfect  in  every  respect. 

Mumps. — The  peculiar  poison  which  causes  the  disease  generally 


380  THE    DISEASES    OF    THE    EAR, 

known  by  the  name  of  mumps  is  very  often  the  source  of  complete 
deafness,  -whicli,  however,  usually  occurs  in  one  ear  only.  In  these 
cases,  the  nervous  apparatus  is  evidently  affected,  as  the  deafness 
comes  on  suddenly,  is  usually  complete,  and,  as  a  general  rule,  no 
appearance  of  disease  can  be  detected  in  the  meatus,  membrana 
tympani,  or  tympanic  cavity.  When  the  nerve  is  not  wholly  para- 
lyzed, and  some,  although  it  may  be  a  very  slight  degree  of,  hear- 
ing remains,  the  only  plan  of  treatment  which  can  be  recommended, 
is  the  use  of  gentle  counter-irritation  over  and  around  the  ears,  at 
the  same  time  that  the  ear  is  exercised  by  means  of  the  elastic  speak- 
ing-tube. 

The  circulation  of  bile  mixed  with  the  blood  is  sometimes  a  cause 
of  deafness,  and  it  is  also  well  knoAvn  that  large  doses  of  quinine 
are  also  liable  to  be  followed  by  temporary  deafness.  I  have  met 
with  only  one  case  in  which  permanent  injury  to  the  ear  was 
assigned  to  the  use  of  large  doses  of  quinine. 

The  poison  o^  gont  may  also  give  rise  to  deafness  and  other  pecu- 
liar symptoms  in  the  head.  In  two  cases  of  this  affection  which 
came  under  my  notice,  it  is  interesting  to  observe  that  the  head- 
symptom  complained  of,  viz.,  a  feeling  of  vacancy,  was  at  once 
relieved  by  pressure  upon  the  air  contained  in  the  external  meatus. 

Distressing  sensations  produced  in  the  ears  by  gout. — D.  T.,  Esq., 
aged  54,  consulted  me  in  June,  1857.  He  said  that  for  the  last 
four  or  five  years  he  had  ])een  subject  to  attacks  of  gout,  Avhich  had 
at  times  caused  him  great  inconvenience,  and  the  disease  had  recently 
made  so  much  progress  as  to  make  him  fearful  that  his  brain  was 
weakened  by  its  influence.  lie  added  that  he  was  never  really  clear- 
headed, excepting  just  after  an  attack  of  gout,  when  he  supposed 
his  blood  was  temporarily  freed  from  the  poison.  lie  had  rapidly 
aged  in  the  course  of  the  previous  two  years.  An  extremely  dis- 
tressing symptom  had  lately  presented  itself  in  the  form  of  a  pecu- 
liar sensation  of  vacancy  in  the  ears,  accompanied  sometimes  by  a 
low  hinnming  sound.  There  was  no  deafness,  and  the  patient 
applied  to  me  only  on  account  of  the  sensations  in  the  ear.  On 
examination,  small  deposits  of  gouty  matter  were  oliscrved  in  the 
sul)stance  of  the  right  upper  eyelid  ;  the  surface  of  the  meatus  ex- 
ternus  was  of  a  bright  red  color  ;  the  circumference  of  the  mem- 
br:ina  tympani  and  of  the  long  process  of  tlie  malleus  were  also  red; 
while  the  surface  of  the  tympanic  membrane  was  very  bright.  Air 
passed  freely,  and  with  the  natural  sound,  into  the  tympanic  cavity. 


NERVOUS     DEAFNESS.  381 

The  hearing  power  -was  perfect.  By  -what,  therefore,  coukl  the  dis- 
tressing symptoms  be  caused  ?  Were  they  the  result  of  congestion 
of  the  nerve  ? — a  condition  which,  it  seemed  to  me  probable,  might 
render  the  nerve  so  exquisitely  sensitive,  that  the  ordinary  sounds 
ever  floatinor  in  the  air  niiglit  become  a  source  of  excitement  to  the 
ear.  Being  aware  also,  from  previous  experience  in  similar  cases, 
that  pressure  upon  the  external  meatus  so  as  to  shut  out  or  diminish 
the  sound  in  the  meatus  would  remove  the  symptom  complained  of, 
I  closed  with  my  fingers  each  external  meatus,  and  the  unpleasant 
symptoms  at  once  disappeared.  On  subsequently  exerting  a  gentle 
pressure  on  the  ears  by  the  introduction  of  cotton  steeped  in  water 
into  each,  the  patient  was  enabled  to  leave  in  comparative  comfort. 
For  the  purpose  of  preventing  the  recurrence  of  the  symptoms,  it 
was  of  course  requisite  to  diminish  the  congestion,  for  which  pur- 
pose two  leeches  Avere  applied  below  each  ear,  small  doses  of  colchi- 
cum  administered,  and  strict  attention  to  diet  enjoined.  The  quan- 
tity of  wine  was  decreased  from  four  to  two  glasses  daily,  and  in 
lieu  of  beef  and  mutton,  of  which  he  had  been  in  the  habit  of  partak- 
ing very  abundantly,  he  was  ordered  to  live  principally  on  poultry, 
game,  and  fish,  with  abundance  of  farinaceous  food  and  vegetables. 
The  result  of  this  treatment  was  the  removal  of  the  distressing 
symptoms  in  the  ears,  and  the  gradual  disappearance  of  the  attacks 
of  gout. 


(b.)   DISEASES   IN   WHICH    THE    BRAIN   AS    WELL   AS   THE    EAR, 
APPEARS   TO    BE   AFFECTED. 

(1.)  Debility  of  the  nervous  apparatus  arising  from  mental 
excitement, 

A  young  lady,  of  about  25  years  of  age,  is  brought  to  me  by  her 
mother,  on  account  of  deafness  in  both  ears,  one  being  much  deafer 
than  the  other.  The  patient  is  pale,  rather  thin,  and  has  a  look  of 
depression.  She  complains  of  humming  noises  in  both  ears,  and 
hears  better  in  a  carriage.  Upon  examination  her  pulse  is  feebler 
than  natural,  and  the  deafness  is  so  considerable  that  she  requires 
to  be  loudly  spoken  to  within  a  yard  of  her  ears.  There  is  no  mor- 
bid appearance  in  any  part  of  the  ear,  and  the  Eustachian  tube  is 
in  a  natural  state.  On  inquiring  as  to  the  origin  of  the  deafness, 
the  parent  states  that  they  had  not  been  able  to  detect  any  cause. 


382  THE     DISEASES    OF    THE    EAR. 

The  ilcafnc-ss  came  on  three  years  previously,  when  the  young  lady 
was  in  good  health,  and  gradually  increased,  till  in  four  months  the 
patient  had  become  as  deaf  as  now.  She  is  rather  deafer  after  ex- 
citement and  during  fatigue.  There  is  no  hereditary  tendency  to 
deafness.  The  young  lady  has  remained  at  home  with  her  mother, 
has  taken  plenty  of  exercise  in  the  open  air  daily,  and  retired  to 
bed  early  ;  but,  for  some  reason  or  other,  her  nervous  system  was 
not  strong,  and  she  was  easily  excited.  On  further  questioning, 
it  is  found,  that  about  the  period  when  the  deafness  came  on,  the 
patient  Avas  particularly  nervous,  and  ultimately  it  turns  out,  by  her 
confession,  that  she  had  been  deeply  grieved  by  the  conduct  of  one 
of  her  friends,  and  had  often  lain  awake  at  night  indulfrinij  in  sor- 
row,  and  that,  at  such  periods,  the  noises  came  on  in  increased 
force. 

Another  young  lady,  aged  10,  is  brought  just  after  leaving  school, 
where  she  was  well  taken  care  of,  and  so  liked  l)y  all,  that  she  even 
preferred  school  to  home.  Iler  parents  stated  that  six  months 
before,  without  any  apparent  cause,  their  daughter  had  grown  gra- 
dually deaf,  and  can  at  present  hear  only  when  very  distinctly  spoken 
to,  Avithin  a  distance  of  tAvo  or  three  yards.  The  deafness  is  Avorse 
during  excitement.  There  is  no  appearance  of  disease  in  the  ears, 
and  the  girl  is  strong,  active,  and  healthy ;  her  nerA'ous  system  is, 
hoAvever,  very  sensitive,  her  feelings  most  acute,  and  she  broods  in 
silence  over  slight  mental  troubles  Avhicli  Avould  pass  unheeded  by 
ordinary  persons.  Perhaps  all  attempts  to  find  out  the  cause  of  the 
deafness  are  in  vain  ;  and  the  parents  go  away  Avith  the  assurance 
from  the  medical  man,  that  at  the  time  the  deafness  first  appeared 
there  must  have  been  some  cause  of  mental  excitement  to  call  it 
forth.  After  the  lapse  of  a  shorter  or  longer  period,  the  medical 
man  learns,  perhaps,  that  at  the  time  in  question  the  young  lady  at 
school  suffered  a  great  deal  of  mental  anxiety,  OAving  to  her  reli- 
gious vicAAs  being  in  an  unsettled  state. 

These  tAvo  cases  are  good  t^'pcs  of  the  class  of  nervous  deafness 
now  under  consideration.  The  causes  may  be  very  numerous,  and 
in  some  instances  are  but  slight,  compared  Avith  the  distressing 
symptoms  Avhich  ensue  ;  but  it  must  be  borne  in  mind  that,  as  a 
general  rule,  the  nervous  system  has,  from  a  variety  of  causes,  been 
alloAved  to  sink  into  a  Aveakened  condition.  Thus  the  child  may  have 
been  overworked,  liave  suffered  from  indigestion,  had  too  little  exer- 
cise or  not  enough  sleep  :  ventilation  also  may  liave  been  defectiA'c. 


NERVOUS     DEAFNESS.  383 

In  a  depressed  state  of  health  from  any  of  these  causes,  an  appa- 
rently slight  additional  cause  may  produce  the  injurious  efi'ect  on 
the  nervous  system  which  hag  been  indicated  Sometimes  there  is 
no  diminution  of  the  hearing  power,  and  the  patients  complain  not 
of  deafness,  but  rather  of  singing  noises,  which  are  increased  by 
any  mental  excitement.  In  some  cases  the  noises  are  not  constant, 
but  only  appear  after  mental  emotion  ;  the  slightest  unpleasant 
thoughts  are  sometimes  sufficient  at  once  to  induce  the  noises. 

The  deafness  and  noises  in  this  class  of  cases,  if  slight,  can  be 
cured  by  removing  the  cause  (a  depressed  state  of  health),  and  by 
giving  tone  to  the  nervous  system  by  tonics  and  by  local  applica- 
tions to  the  ear.  In  some  cases,  however,  of  this  species  of  nervous 
deafness,  the  symptoms  of  noises  become  so  greatly  aggravated, 
that  unless  their  peculiar  character  had  been  detailed  by  several 
patients,  it  would  be  difficult  to  credit  their  existence.  They  may 
commence  with  a  gentle  singing,  then  increase  to  a  hissing  or  wiz- 
zing  sound,  that  suddenly  changes  to  a  series  of  sharp  cracks,  like 
pistol-shots,  followed  by  a  rushing  sound  like  the  wind,  or  the  escape 
of  steam  from  a  boiler,  after  which  a  rolling  may  ensue  like  thunder. 
These  sounds  vary  much  in  intensity,  being  increased  in  some  by 
rainy  weather,  in  others  by  an  easterly  wind  ;  bodily  fatigue  may 
sometimes  cause  them  to  be  magnified,  but  the  source  of  increase  is 
usually  some  discomfort  or  excitement  of  mind.  A  young  lady,  for 
instance,  comes  into  my  room  with  her  mother  to  consult  me,  and 
she  says  that  the  noises  became  rather  worse  than  usual  when  told 
that  she  was  going  to  see  a  medical  man  ;  that  they  Avere  accelerated 
when  entering  my  house  and  waiting  in  the  dining-room  ;  and  that 
they  reached  their  acme  of  intensity  after  the  excitement  attendant 
upon  my  examination  of  the  ears,  and  questioning  her  about  the 
symptoms.  The  important  problem  for  consideration  is,  can  the 
ears  be  improved  ?  So  far  as  my  present  experience  extends,  I  may 
say  that  a  large  number  of  the  worst  cases  can  be  but  slightly  in- 
fluenced by  treatment;  but  there  is  still  a  large  number  which  may 
be  very  greatly  benefited  by  measures  calculated  to  brace  the  nerv- 
ous system ;  as  tonics,  fresh  air,  exercise,  and  mental  repose.  In 
these  cases  I  am  giving  electricity  a  trial. 

Dchility  of  the  nervous  apparatus  of  the  car,  produced  hy  over- 
study. — Lady  D.  brought  her  child  to  me  in  June,  1852.  The  young 
lady  was  twelve  years  of  age,  thin,  rather  tall  of  her  age,  and  pale. 
The  pulse  was  weak  ;  the  tonsils  large  and  red  ;  the  mucous  mem- 


384  THE     DISEASES    OF    THE    EAR. 

brane  of  the  fauces  red,  thick,  and  rugous.  The  sub-maxillary 
glands  were  somewhat  enlarged,  and  she  had  been  subject  to  glandu- 
lar swellings  in  the  neck.  The  appetite  was  good,  and  she  partook 
freelv  of  meat  twice  daily.  She  was  taught  at  home  with  her  sister 
by  two  governesses,  one  being  for  languages.  She  devoted  between 
eight  and  nine  hours  daily  to  her  studies.  The  history  given  me 
was,  that  during  the  last  two  years,  without  any  assignable  cause, 
the  power  of  hearing  had  gradually  diminished,  and  there  had  been 
slight  noises  in  the  ears  at  times.  On  inquiry,  it  was  elicited  that 
she  was  greatly  interested  in  her  studies,  and  very  anxious  to  make 
progress  in  them,  never  much  tiring  of  her  lessons.  Her  interest 
in  them  increased  to  excitement,  and  she  was  often  agitated  and 
distressed  at  not  being  able  to  accomplish  as  much  as  she  desired. 
On  examining  the  ears,  a  slight  dulness  was  observable  in  each 
membrana  tympani ;  the  Eustachian  tubes  were  pervious,  but  the 
hearing  power  was  so  diminished,  that  she  required  to  be  loudly 
spoken  to  within  a  yard  of  the  head. 

This  deafness  was  at  times  so  greatly  aggravated,  that  consider- 
able difficulty  was  experienced  in  making  the  patient  hear  at  all. 
It  was,  therefore,  palpable  that  there  was  considerable  debility  of 
the  nervous  apparatus  of  each  ear,  for  which  tonics  were  prescribed, 
also  a  gentl^^-stimulating  embrocation  ;  fewer  hours  were  to  be  de- 
voted to  study,  and  light  nutritious  food,  as  game,  poultry,  fish, 
was  to  be  taken  instead  of  so  much  meat.  All  this  resulted  in 
some  slight  amelioration ;  but  still  the  deafness  was  very  con- 
siderable, and  increased  greatly  at  times.  Under  the  circum- 
stances, another  consultation  took  place,  at  which  I  clearly  traced 
the  attacks  of  increased  deafness  to  more  than  usual  nervous  ex- 
citement following  more  than  usual  mental  work.  In  addition  to 
the  previous  tonic  measures,  entire  rest  from  study  in  any  shape 
was  enjoined  for  three  months,  during  the  whole  of  which  time  the 
hearing  gradually  improved,  and  at  the  end  of  six  months  the 
patient  was  declared  to  be  perfectly  well ;  and,  although  she  has 
resumed  her  previous  plans  of  study,  moderated  according  to 
circumstances,  the  case  remains  satisfactory. 

To  the  above  case  the  details  of  several  others  might  be  added, 
were  not  a  brief  allusion  sufficient.  Thus  a  lady,  aged  27,  consults 
me  for  deafness  accompanied  by  noises  Avhich  gradually  came  on 
during  the  previous  four  years.  The  nervous  system  never  was 
strong,  but  underwent  a  severe  shock,  about  the  commencement  of 


NERVOUS    DEAFNESS.  385 

the  period  mentioned,  from  the  breaking  off  of  a  matrimonial  en- 
gagement. With  the  continuance  of  the  mental  sorrow  the  deaf- 
ness and  noises  had  gradually  increased,  and  were  always  accelerated 
after  much  mental  dejection. 

Another  lady  of  nervous  temperament  and' warm  feelings,  was 
sitting  at  home  awaiting  the  return  of  a  brother  to  whom  she  was 
greatly  attached,  when  he  was  brought  home  dead  from  a  fall  in 
the  street.  For  the  space  of  a  year  the  sister  gave  way  to  despon- 
dency, and,  as  she  told  me,  the  thought  of  her  brother  during  the 
whole  year  was  scarcely  a  moment  absent  from  her  mind.  At  the 
end  of  that  time,  as  her  spirits  began  to  improve,  noises  appeared 
in  the  ears  and  head,  dulness  of  hearing  followed,  and  both  noises 
and  deafness  so  greatly  increased,  that  in  the  course  of  another 
year,  when  seen  by  me,  she  was  so  hard  of  hearing  as  to  require  to 
be  loudly  addressed  at  the  distance  of  a  yard  or  two,  while  the 
noises  had  reached  a  pitch  of  extraordinary  excitement.  There 
was  scarcely  any  conceivable  sound,  whether  of  thunder,  cannon, 
firing  guns,  bells,  hissing,  rolling  of  the  sea  against  the  beach  in  a 
storm,  or  winds  howling,  to  which  this  lady  was  not  subject.  These 
sounds  intermixed  and  alternated  in  a  manner  quite  indescribable. 
They  remained  of  the  same  general  intensity,  varying  somewhat 
according  to  the  weather,  for  several  years ;  when  another  severe 
domestic  bereavement  occurred,  followed  by  some  new  noises  of  a 
still  more  intense  character,  but  her  deafness  remained  much  the 
same. 

Another  lady,  who  married  at  about  26  years  of  age,  was  sub- 
jected to  severe  domestic  trials,  which,  after  preying  upon  her  mind 
for  some  years,  ended  in  such  total  deafness,  that  she  could  not  hear 
a  pistol-shot  fired  close  to  her  head. 

The  variable  amount  of  deafness  in  this  class  of  cases  is  sometimes 
very  marked.  Thus,  I  had  for  a  long  while  a  patient  under  my  care 
who,  when  perfectly  tranquil,  could  distinctly  hear  his  daughter 
reading  to  him  at  about  the  distance  of  a  yard ;  but  if  his  daughter 
told  him  anything  which  excited  his  interest,  he  became  so  thoroughly 
deaf  as  not  to  be  able  to  hear  a  sound,  and  would  remain  so  until  the 
excitement  vanished,  when  his  hearing  would  return. 


25 


386  THE     DISEASES    OF    THE     EAR. 


(2.)  DehiUty  of  the  nervous  apparatus  of  the  ear  produced  hy 
general  bodily  debility. 

It  is  difficult  to  th'aw  a  correct  comparison  between  the  number 
of  cases  of  deafness  dependent  upon  excess  of  mental  excitement, 
and  those  arising  from  overtasking  the  body ;  but  from  the  data 
before  me,  perhaps  those  of  the  class  now  to  be  considered  arc 
the  most  common.  They  occur  in  both  sexes,  but  are  more  fre- 
quently met  with  in  the  female ;  and  present  great  variety  of  form 
as  well  as  cause.  Sometimes  they  are  temporary,  and  produced  by 
a  long  walk,  heated, rooms,  late  hours,  &c.,  when  noises,  with  di- 
minished hearing  power,  come  on,  but  disappear  after  rest.  Other 
cases,  and  even  some  of  those  which  come  on  suddenly,  may,  how- 
ever, remain  more  or  less  permanent.  Thus,  cases  have  been  met 
with  in  my  experience,  in  which  patients  have  become  totally  deaf 
after  the  administration  of  too  violent  a  purgative,  or  after  an  attack 
of  diarrhoea  or  cholera,  and  after  the  nervous  exhaustion  attendant 
upon  childbirth  ;  in  some  instances  of  the  latter,  the  deafness  has 
begun  with  the  birth  of  the  first  child,  and  increased  with  each 
successive  birth,  until  at  last  the  nervous  power  was  wholly  lost. 
Perhaps  the  most  common  cause  of  nervous  deafness  from  physical 
debility  is  the  want  of  proper  care  in  the  management  of  young 
persons,  and  particularly  girls,  when  they  are  growing  fast.  In 
hospital  practice,  young  nursemaids  who  carry  heavy  children,  and 
whose  night's  rest  is  often  disturbed,  and  youths  just  entering 
laborious  situations,  are  found  to  suffer.  Any  cause,  in  fact,  which 
reduces  the  nervous  energy  of  the  body  to  a  state  too  low  for  the 
due  regulation  of  the  functions  of  the  various  orf!;ans  of  the  frame, 
may  be  followed  by  a  manifest  depression  of  the  nervous  power  of 
the  ears,  which  shows  itself  not  merely  in  diminished  power  of  hear- 
ing, but  often  by  singing  and  other  sensations  in  the  ear,  and  some- 
times by  severe  pain,  like  tic  doloureux.  In  cases  where  debility  of 
the  nervous  system  of  the  ear  is  the  result  of  a  debilitated  state  of 
the  body,  the  pulse,  as  a  general  rule,  is  weak,  and  there  are  symp- 
tt)ms  of  previous  or  present  indigestion.  Generally,  no  unhealthy 
condition  of  the  organ  itself  is  apparent ;  though,  in  recent  cases, 
the  cerumen  may  be  softer  and  more  abundant  than  usual,  and  in 
old  standing  cases  may  even  be  absent. 

The  treatment  of  cases  of  debility  of  the  nervous  apparatus  of  the 


NERVOUS     DEAFNESS.  387 

ear  arising  from  bodily  debility,  consists  in  imparting,  by  every 
possible  means,  strength  to  the  general  system.  Exercise  in  the 
open  air,  a  due  amount  of  rest  and  sleep,  -well-ventilated  rooms  by 
day  and  night,  abundance  of  nutritious  food,  stimulants  in  modera- 
tion, tonics  in  the  shape  of  quinine,  bark,  strychnine,  creasote,  &c., 
should  be  prescribed ;  Avhilc  locally,  gentle  stimulants  should  be 
applied  over  and  around  the  car.  I  have  never  found  the  vapor 
of  ether  applied  to  the  tympanic  cavity  by  means  of  the  Eustachian 
catheter  of  any  service ;  nor  has  my  limited  experience  of  the  use 
of  galvanism  and  electricity  hitherto  been  favorable  to  their  em- 
ployment. Some  cases  are  decidedly  amenable  to  treatment,  and 
the  noises  diminish  or  disappear,  while  the  deafness  is  greatly 
diminished ;  but  if  the  cause  in  Avhich  the  deafness  originated  be 
allo\yed  to  continue,  or  if  any  debilitating  influence  be  present,  total 
deafness  may  ensue  in  spite  of  every  remedial  effort.  The  following 
cases  are  all  interesting. 

Deafness  produced  by  want  of  sufficient  sleep  ;  cure. — In  the  earl}^ 
part  of  1855,  a  young  gentleman,  aged  14,  was  brought  to  me  by 
his  father,   on  account  of  gradually  increasing  deafness.     lie  ap- 
peared to  be  in  tolerable  health,  and  was  at  school  in  the  neighbor- 
hood of  London.     No  cause  could  be  assigned  for  the  afiection,  which 
had  so  far  advanced  as  to  cause  him  great  discomfort  from  his  ina- 
bility to  hear  what  his  masters  said  to  him.     On   examination,  it 
became  apparent  that  the  deafness  depended  upon  debility  of  the 
nervous  system,  for  there  was  no  history  of  any  other  disease,  nor 
was  there  any  appearance  indicative  of  disease.     The  patient  had, 
however,  occasional  noises  in  the  ears,  following  over-exertion,  and 
he  certainly  was  deafer  when  he  was  tired.     On  inquiry,  I  could 
discover  no  special  cause  for  the  deafness,  as  he  followed  the  same 
rules   and  regulations  which  Avere  pursued  by  all  the  boys  in  the 
school.     I  prescribed  internally  quinine,  and  a  stimulating  liniment 
externally,   giving  directions   that  he  should  not  be  over-Avorked. 
In  a  month's  time  the  boy  Avas  seen  again,  but  remained  in  much 
the  same  state,  so  I  requested  to  be  alloAved  to  see  the  lady  with 
Avliom  he  boarded,  in  order  to  ascertain  further  particulars  as  to  his 
mode  of  living.     On  the  most  minute  questioning  no  sufficient  cause 
could  be  detected,  except  that,  being  very  desirous  to  prepare  his 
lessons  Avell,  he  sat  up  so  late  that  Avlien  the  time  arrived  for  getting 
up,  he  Avas  so  sleepy  as  to  be  roused  Avith  difficulty.     It  Avas  at  once 
rendered  probable,  that  the  debility  of  the  nervous  apparatus  of  the 


388  THE    DISEASES    OF    THE    EAR. 

ear  might  be  dependent  upon  the  want  of  sleep ;  and  I  therefore 
recjuested  his  friends  to  see  that  his  duties  were  so  relaxed  that  he 
could  take  as  much  sleep  as  he  required,  and  gave  directions  that 
he  should  go  to  bed  at  eight  o'clock,  and  sleep  until  he  awoke  of  his 
own  accord.  The  result  was,  that  for  several  successive  nights,  he 
slept  for  fourteen  hours,  and  by  degrees  the  number  was  reduced  to 
ten,  which  was  his  usual  allowance  for  three  weeks,  at  the  end  of 
which  time  he  returned  to  me,  when,  to  the  gratification  of  all,  it 
was  found  that  his  hearing  was  nearly  restored,  and  he  was  no  longer 
styled  "  the  deaf  boy"  at  school.  This  patient  has  been  seen  by  me 
twice  or  thrice  since,  at  considerable  intervals,  in  consequence  of 
the  deafness  returning ;  but  each  time  it  was  evident  that  the  ner- 
vous system  had  been  too  much  exhausted,  and  the  administration 
of  quinine,  with  less  work,  and  an  increase  in  the  amount  of  sleep, 
soon  restored  the  hearing. 

Total  deafness  produced  hy  the  nervous  shock  consequent  upon 
successive  accouche j?ients. — Mrs.  B.,  aged  40,  pale,  and  of  a  nervous 
temperament,  consulted  me  in  1850,  on  account  of  complete  deaf- 
ness in  both  ears.  She  stated  that  she  had  married  in  India  ten 
years  previously,  and  at  the  time  of  her  marriage  she  could  hear 
perfectly  well.  On  the  occasion  of  her  first  confinement,  previous 
to  which  her  hearing  was  still  perfect,  she  sufiered  a  good  deal  from 
exhaustion,  and  this  was  followed  by  a  great  degree  of  deafness,  so 
that  she  could  scarcely  hear  what  was  said  to  her,  even  when  the 
voice  was  much  raised.  Upon  getting  up,  and  growing  stronger, 
the  deafness  was  so  much  relieved  that  she  merely  required  to  be 
spoken  to  a  little  louder  than  usual.  During  each  successive  con- 
finement in  India,  amounting  in  all  to  four,  the  deafness  greatly  in- 
creased, and  after  each  recovery  became  more  permanent,  until,  on 
the  last  occasion,  she  remained  as  deaf  as  at  present,  when  she  is 
oblir'ed  to  have  recourse  to  signs.  Indeed,  she  has  never  heard  the 
voices  of  her  younger  children,  and  can  only  by  the  movements  of 
their  lips  understand  their  words. 

Debility  of  the  nervous  apparatus  of  the  ear  arising  from  over- 
exhaustion  in  India. — Captain  T.,  aged  40,  came  home  from  India 
in  18')8,  having  undergone  great  fatigue,  and  his  health  having  been 
greatly  shattered,  while  his  hearing  power  had  so  much  diminished, 
that  when  he  consulted  me  I  was  obliged  to  speak  very  distinctly 
within  a  yard  of  his  head.  He  complained  of  constant  loud  singing 
in  the  ears,  which  was  increased  by  the  slightest  exertion.     On  ex- 


NERVOUS    DEAFNESS.  389 

amining  the  ears,  no  alteration  from  tlie  normal  condition  could  be 
detected,  and  the  Eustachian  tubes  Avere  in  a  natural  state.  The 
treatment  consisted  in  sending  the  patient  to  the  seaside  and  in 
giving  him  quinine,  using  at  the  same  time  a  stimulating  liniment 
over  the  ears  and  at  the  back  of  the  neck.  In  two  months  his 
strength  had  greatly  increased,  with  a  corresponding  improvement 
in  the  hearing.  He  returned  to  the  seaside  to  pursue  the  treatment 
in  capital  spirits,  and  was  induced  to  go  out  on  two  consecutive  days 
to  evening  parties,  at  which  he  stayed  till  very  late.  Nervous  ex- 
haustion followed,  and  his  hearing  sank  to  the  same  low  ebb  as  when 
he  first  consulted  me  :  nor  was  it  until  after  two  months  of  very 
quiet  life  and  steady  keeping  to  the  prescribed  treatment,  that  he 
again  began  to  improve. 

Nervous  deaftiess  produced  hy  over-exertion. — E.  Clarke,  aged  31, 
a  tall  muscular  carter,  was  admitted  under  my  care  at  St.  Mary's 
Hospital,  on  January  27th,  1859.  He  stated,  that  fourteen  years 
before,  when  out  of  health,  deafness  came  on  in  the  left  ear,  accom- 
panied by  noises,  sometimes  like  a  kettle  singing,  at  others,  like  the 
ringing  of  bells.  On  recovering  his  health,  he  found  himself  per- 
fectly deaf  in  the  left  ear,  which  has  remained  so  ever  since.  Eleven 
weeks  ago,  when  a  good  deal  exhausted  by  hard  work,  he  took  a  bad 
cold,  daring  which  singing  came  on  in  the  right  ear,  with  loud  noises, 
like  the  ringing  of  bells,  and  were  accompanied  with  so  serious  an 
amount  of  deafness,  that  he  required  to  be  spoken  to  in  a  loud  voice, 
within  a  yard  of  his  head.  The  patient's  pulse  Avas  weak,  and  he 
had  a  worn  aspect,  as  from  exhaustion  of  the  nervous  system.  On 
examination,  no  appearance  of  disease  Avas  visible  in  either  ear,  and 
the  Eustachian  tubes  Avere  pervious.  Two  grains  of  quinine  were 
ordered  to  be  taken  tAvice  daily,  and  a  stimulating  liniment  to  be 
rubbed  over  the  surface  of  the  ears,  at  the  back  of  the  neck,  and 
doAvn  the  spine.  In  the  course  of  a  Aveek  the  noises  decreased 
greatly,  and  in  a  fortnight  they  had  Avholly  disappeared,  while  the 
hearing  poAver  gradually  increased  ;  so  that  Avhen  he  left  the  hospi- 
tal, at  the  end  of  six  Aveeks,  to  use  his  oaa'u  words,  he  "  at  times 
hears  quite  nicely." 

Several  cases  of  a  similar  character  might  be  cited,  in  Avhich  equally 
favorable  results  folloAved  the  administration  of  strychnine,  in  doses 
varying  from  one-thirtieth  to  one-tAventieth  of  a  grain,  tAvice  or  thrice 
daily ;  and  in  some  instances,  Avhere  neither  quinine  nor  strychnine 


390  THE     DISEASES    OF    THE    EAR. 

were  of  any  benefit,  doses  of  creasote,  or  of  morphia,  or  of  both  to- 
gether, "vvere  productive  of  great  improvement. 

Kervous  deafness  relieved  by  creasote  and  morphia. — Miss  M., 
aged  29,  in  good  health,  but  very  easily  excited,  consulted  me  in 
January,  1859,  on  account  of  deafness.  Four  years  previously  her 
left  car  gradually  became  deaf,  accompanied  with  noises  very  diffi- 
cult to  describe,  but  something  like  a  whizzing,  and  these  noises 
were  increased  by  any  external  noise,  or  if  she  felt  nervous,  tired, 
or  excited,  and  were  worse  at  night.  In  a  few  months  the  right 
ear  was  also  affected  in  the  same  way.  In  both  the  deafness  was 
gradually  increasing.  This  deafness  was  also  accompanied  by  a 
sudden  loss  of  voice  after  she  had  spoken  a  few  words.  The  only 
cause  to  which  she  can  ascribe  the  deafness  was  the  habit  of  going 
for  many  hours  without  food,  and  then  eating  very  rapidly.  She 
had  been  treated  by  blisters,  whose  use  had  been  followed  by  a  rapid 
advance  of  the  deafness,  and  she  had  been  told  that  her  case  was  in- 
curable. At  the  time  of  her  first  consulting  me,  it  was  requisite  to 
speak  loud  Avithin  a  yard  of  her  head,  and  she  was  deaf  to  all  gene- 
ral conversation.  On  examination,  each  membrana  tympani  had  a 
perfectly  natural  appearance,  and  the  Eustachian  tubes  were  healthy. 
The  treatment  consisted  in  using  gentle  counter-irritation  over  each 
ear,  the  back  of  the  neck,  and  down  the  spine,  and  in  administering 
creasote  and  morphia,  in  doses  of  two  or  three  minims  of  the  former 
to  one-twelfth  of  a  grain  of  the  latter,  twice  daily.  This  treatment 
was  continued  perseveringly  for  four  months,  at  the  same  time  that 
every  measure  for  restoring  the  general  health  as  respects  food,  ex- 
ercise, and  diet,  were  resorted  to,  and  at  the  end  of  the  treatment 
the  hearing  power  was  so  greatly  improved  that  she  could  both  hear 
and  take  part  in  general  conversation. 

Cases  of  nervous  affection  of  the  ear  sometimes  occur  in  which  the 
chief  symptom  is  i)ain  ;  the  treatment  does  not  differ  from  that  of 
the  last  class  of  cases. 

Pain  in  the  left  ear,  accompanied  hy  diminished  power  of  hearing, 
folloiving  overfatigue. — Miss  T.,  aged  25,  pale  and  not  strong,  was 
brought  to  consult  me,  in  May,  185G,  on  account  of  a  pain  in  the 
left  ear  ;  this  pain  had  made  its  first  appearance  about  a  year  before 
after  the  patient  had  undergone  considerable  fatigue  by  attending 
several  evening  parties  in  succession,  and  remaining  very  late;  and 
the  pain  Avas  much  accelerated  by  any  cause  which  produced  fatigue. 
The  hearing  power  was  very  slightly  affected ;  and  as  the  other  ear 


NERVOUS     DEAFNESS.  391 

was  perfect,  no  complaint  Avas  made  respecting  the  hearing.  On 
examination,  the  organ  appeared  to  he  quite  healthy ;  and  feeling 
that  the  pain  arose  from  deranged  action  of  the  nerve  consequent 
upon  dehility,  quinine  "was  prescribed  internally,  and  mild  stimulants 
applied  over  the  ear  and  down  the  spine.  This  treatment  was  fol- 
lowed by  considerable  success,  as  the  pain  disappeared  in  the  course 
of  a  month,  but  returned  slightly  upon  the  patient  having  to  undergo 
great  fatigue. 


CHAPTER    XVI. 

THE  DISEASES  OF  THE  NERVOUS  APPARATUS  {concluded). 

ULCERATION  OK  TUE  MEMBRANOUS  LABYRINTH — CARIES  AND  NECROSIS  OF  THE 
PETROUS  BONE. 

In  the  cases  hitherto  described  of  disease  extending  from  the  tym- 
panic cavity  to  the  brain,  tlie  upper  osseous  wall  of  the  tympanum 
was  the  part  affected,  and  the  medium  through  which  disease  ad- 
vanced to  the  middle  cerebral  cavity.  There  is,  however,  another 
medium  by  which  disease  may  be  conveyed  from  the  tympanic  cavity 
to  the  brain  ;  and  that  is  through  the  labyrinth.  When  it  is  re- 
membered that  at  the  inner  wall  of  the  tympanum  a  delicate  mem- 
brane (membrana  fenestrre  rotunda?)  is  all  that  separates  it  from  the 
cochlea,  and  that  the  base  of  the  stapes  with  its  fine  ligaments  form 
the  only  septum  between  that  wall  and  the  vestibule,  it  will  natu- 
rally be  inferred  that  disease  in  the  tympanic  cavity  would  fre- 
quently advance  to  the  labyrinth.  The  occurrence  is,  however,  in 
fact,  very  rare,  for  this  reason,  that  ulceration  of  the  mucous  mem- 
brane of  the  tympanum  is  far  from  a  common  disease,  while,  under 
the  influence  of  chronic  inflammation  and  of  the  secretion  collected 
in  the  tympanum,  the  membranes  both  of  the  fenestra  rotunda  and 
ovalis  become  thickened  and  turgid. 

I  am  not  aware  that  any  case  has  been  recorded  in  which  disease 
had  made  its  way  through  the  fenestra  rotunda  to  the  labyrinth  ; 
but  in  the  course  of  my  dissections  I  have  found  the  medium  of 
communication  to  have  been,  in  one  instance,  the  fenestra  ovalis, 
and,  in  the  other,  a  carious  aperture  in  the  outer  arm  of  the  ex- 
ternal semicircular  canal,  where  it  bulges  into  the  tympanic  cavity, 
and  is  covered  by  the  tympanic  mucous  membrane.  "When  suppu- 
ration takes  place  in  the  labyrinth,  the  disease  readily  advances 
through  the  cribriform  floor  of  the  meatus  auditorius  internus  to  the 
auditory  nerve,  and  thence  to  the  base  of  the  brain  and  medulla  ob- 


NERVOUS     DEAFNESS.  393 

longata.  In  certain  cases  purulent  matter  is  efTused  beneath  the 
arachnoid  over  the  whole  surface  of  the  base  of  the  brain,  surround- 
ing the  nerves  in  their  cranial  course;  and  the  substance  of  the  pons 
Varolii  or  medulla  oblongata  may  be  destroyed  by  ulceration,  or  an 
abscess  may  form  between  the  arachnoid  and  pia  mater.  In  some 
cases  the  disease  extends  a  considerable  distance  down  the  medulla 
spinalis. 

In  some  cases  the  labyrinth  becomes  carious  or  necrosed,  and  the 
dead  bone  is  discharged  without  the  production  of  any  symptoms 
of  cerebral  disturbance,  as  in  the  following  cases.  The  first  oc- 
curred to  my  friend  Mr.  Hinton,  who  kindly  placed  the  preparation 
in  my  museum.  It  was  of  a  man  net.  55,  who  suifered  from  a  dis- 
charge from  the  right  ear  for  some  years,  and  at  last  the  cochlea 
was  discharged  entire.  The  second  case  occurred  to  Mr.  Shaw,  and 
the  following  report  is  extracted  from  the  seventh  volume  of  the 
Transactions  of  the  Pathological  Society  of  London : — 


Extraction  from  the  left  ear  of  a  hoy  of  the  greater  jJart  of  the  jJetrosal 
portion  of  the  temporal  bone,  including  the  meatus  auditorius  in- 
ternus  and  labyrinth,  separated  by  necrosis. 

"A  boy  from  the  country,  net.  7,  Avas  admitted  into  the  Middlesex 
Hospital  on  the  31st  of  July,  1855,  under  Mr.  Shaw,  for  otorrhoea 
aifecting  both  ears.  The  disease  succeeded  a  severe  attack  of  scar- 
let  fever,  Avhich  he  had  two  years  and  a  half  ago.  From  the  right 
ear  the  discharge  of  pus  was  not  of  great  amount.  The  left  ex- 
ternal ear  projected  considerably  beyond  its  proper  level,  and  an 
irregular  piece  of  bone,  surrounded  with  fungous  granulations,  pro- 
truded from  the  meatus  into  the  concha.  He  had  paralysis  of  the 
muscles  of  the  left  side  of  the  face  ;  for  a  year  he  had  been  com- 
pletely deaf  in  both  ears. 

"  On  the  3d  of  August,  he  was  put  under  the  influence  of  chlo- 
roform, when  Mr.  Shaw  first  extracted  the  piece  of  bone  which 
projected  into  the  concha ;  this  appeared  to  have  been  the  posterior 
border  of  the  external  meatus  of  the  temporal  bone. 

"  The  cartilaginous  tube  having  been  ulcerated  by  the  pressure  of 
the  loose  fragment,  the  point  of  the  little  finger  could  now  be  passed 
inwards  to  some  depth ;  when  another  larger  piece  of  bone  was  felt 
rolling   freely  in    the   cavity.     This  was    seized   by   the    dressing 


394  THE     DISEASES    OF    THE    EAR. 

forceps ;  and  after  it  liad  slipped  once  or  twice,  owing  to  its  hard- 
ness and  smoothness,  it  was  extracted  by  employing  force  and  a 
twisting  motion,  so  as  to  favor  its  coming  in  a  proper  direction.  For 
a  few  seconds  after  the  removal  dark  venous  blood  flowed  rather 
freely.  As  a  precaution,  he  was  kept  in  bed  for  a  week  ;  by  degrees 
the  discharge  lessened,  and  the  ulcer  of  the  tube  cicatrized.  No 
outward  symptoms  arose  ;  and  in  the  end  of  September,  except  from 
the  paralysis  of  the  face,  the  deafness,  and  a  trifling  discharge  from 
both  ears,  he  left  the  hospital  in  good  health." 

Description  of  the  Specimen. — The  density  of  structure,  Aveight, 
and  shape  of  the  portion  of  bone  last  removed,  at  once  showed  that 
it  formed  nearly  the  whole  of  the  petrous  portion  of  the  temporal 
bone.  It  was  of  irregular  cylindrical,  or  rhomboidal  figure  ;  it  mea- 
sured one  inch  in  length ;  its  average  thickness  in  various  directions 
was  half  an  inch ;  it  weighed  twenty-two  grains.  On  one  side, 
nearly  in  its  centre,  was  an  opening  and  cavity  with  well-defined 
borders  and  walls,  which  was  recognized  to  be  the  meatus  audito- 
rius  internus.  The  depth  of  the  meatus,  from  the  margin  to  the 
thin  perforated  plate  through  which  the  auditory  nerve  penetrates 
into  the  labyrinth,  was  three-fifths  of  an  inch  ;  and,  as  that  is  the 
full  depth  of  the  cavity  in  its  normal  state,  it  was  thereby  shown 
that  the  whole  of  the  internal  meatus  was  included  in  the  specimen. 
At  the  bottom  of  the  meatus  could  be  seen  the  commencement  of 
the  canal  for  the  portio  dura.  On  the  side  of  the  specimen  in  rela- 
tion with  the  brain,  the  surface  presented  the  cancellated  appearance 
peculiar  to  the  diploe ;  whence  it  was  concluded  that,  in  the  detach- 
ing of  the  necrosed  part,  the  process  of  separation  had  taken  place 
in  the  diploe — that  the  cortical  layer  had  retained  its  vitality,  and, 
remaining  in  contact  with  the  dura  mater,  had  served  as  a  barrier  to 
prevent  disease  from  extending  to  the  cerebrum.  On  turning  the 
bone  around  to  view  it  in  its  opposite  aspect,  the  side  then  exposed 
was  seen  to  be  the  internal  wall  or  boundary  of  the  tympanic  cavity; 
it  was  easy  to  distinguish  the  ''promontory,"  having  above  it  the 
"fenestra  ovalis,"  and  below  it  the  "fenestra  rotuTida;"  the  two 
latter  openings  were  broken  and  irregular,  and  through  tlie  enlarged 
holes  thus  produced  the  interior  of  the  "vestibule,"  with  its  fossae, 
the  cochlea,  modiolus,  and  lamina  spiralis,  somewhat  injured,  were 
seen.  At  the  posterior  part  of  the  specimen  portions  of  the  semi- 
circular canals,  broken  ofi"  near  their  junction  with  the  vestibule, 
stood  up  distinctly  into  view. 


NERVOUS    DEAFNESS.  395 

In  other  instances,  although  the  brain  is  seriously  implicated,  the 
patients  recover,  as  in  the  following  case  quoted  from  Mr.  Wilde. 
He  says:  "I  am  indebted  to  Sir  Philip  Crampton  for  an  examina- 
tion of  one  of  the  most  extraodinary  pathological  dissections  of 
diseased  bones  perhaps  in  existence,  consisting  of  the  entire  in- 
ternal ear,  cochlea,  vestibulum,  and  semicircular  canals,  "with  a 
small  portion  of  the  inner  -wall  of  the  tympanum,  -which  he  drew 
forth  from  the  meatus  of  a  young  lady  who,  after  the  most  urgent 
symptoms  of  inflammation  of  the  brain,  with  paralysis  of  the  face, 
arm,  and  leg,  and  total  deafness  of  one  side,  recovered  from  the  bad 
symptoms  and  the  paralysis  of  the  extremities  after  a  copious  dis- 
charge from  the  ear.  This  discharge,  the  paralysis  of  the  face,  and 
deafness,  continued  some  time,  accompanied  by  occasional  attacks 
of  pain  in  the  ear,  till  one  day  Sir  Philip,  perceiving  a  portion  of 
loose  bone  lying  deep  in  the  cavity  of  the  meatus,  drew  forth  the 
specimen  from  which  the  illustration  in  the  volume  was  made.  It 
does  not  appear  that  the  hard  external  enamel  of  the  bone  was 
affected,  but  the  scala  cochleae  is  far  more  beautifully  displayed 
than  could  possibly  have  been  done  by  art." 

In  the  following  case,  which,  on  several  grounds,  is  one  of  great 
interest,  the  disease  advanced  through  a  carious  orifice  in  the  semi- 
circular canal  to  the  labyrinth. 

Disease  in  the  tympanic  cavity,  extending  through  a  carious  orifice 
in  one  of  the  semicircular  canals  to  the  labyrinth,  and  thence  hy  the 
auditory  and  facial  nerves  to  the  brain. — On  the  28th  of  March, 
1851,  I  was  called  in  by  Mr.  Such,  of  Dalby  Terrace,  City  Road,  at 
the  request  of  Mr.  Coulson,  who  had  also  seen  the  patient,  to  see  a 
German  gcntleniffti,  aged  26,  the  history  of  whose  case  I  found  to 
be  as  follows  : — He  was  of  a  robust  constitution,  and  had  generally 
enjoyed  the  best  of  health:  indeed,  even  when  first  seen  by  me,  he 
had  the  appearance  of  a  stout,  hcaltliy  man.  Between  four  and 
five  years  previously,  he  complained  of  occasional  pain  in  the  right 
ear,  which  was  usually  followed  by  a  discharge  that  by  degrees  be- 
came constant.  Three  weeks  before  my  seeing  him,  he  suifered 
from  a  severe  attack  of  pain  in  the  head,  which  ceased  on  the 
occurrence  of  an  increased  quantity  of  discharge.  Nothing  par- 
ticular happened  further  until  ten  days  previous  to  my  visit  (except- 
ing a  sleepless  state  at  night),  when  he  was  suddenly  seized  with  a 
violent  pain  in  the  head,  whicli  the  ordinary  remedies  failed  to 
relieve ;  and  by  degrees  this  pain  extended  to  the  back  of  the  neck, 


396  THE     DISEASES     OF    THE    EAR. 

and  as  low  as  the  sixth  dorsal  vertebra.  About  the  same  time 
there  Avas  paralysis  of  the  right  facial  nerve.  For  several  days 
there  had  been  a  continual  shivering  fit  about  two  o'clock  P.M.  On 
the  evening  of  the  28th,  at  whicli  time  I  saw  him,  he  was  suffering 
from  great  pain  at  the  back  of  the  neck ;  was  very  restless,  par- 
ticularly at  times,  but  talked  quite  sensibly ;  the  right  facial  nerve 
was  paralyzed ;  he  squinted,  and  the  pulse  was  85.  The  external 
meatus  was  nearly  filled  by  a  polypus :  the  discharge  was  very 
fetid  and  abundant.  A  large  blister  was  ordered  to  be  applied  to 
the  nape  of  the  neck  ;  the  car  to  be  frequently  syringed  with  hot 
water ;  and,  as  the  patient  was  very  sensitive  to  the  action  of 
mercury,  a  quarter  of  a  grain  of  gray  powder,  Avith  three  grains  of 
extract  of  henbane,  were  administered  every  two  hours. 

March  20th,  9  p.m. — The  mercury  has  already  caused  great  ten- 
derness of  the  gums.  The  symptoms  have  materially  increased ; 
the  pain  at  the  back  of  the  head  was  very  violent  this  morning,  the 
squinting  continues,  and  he  sees  double.  At  three  o'clock  to-day 
he  became  insensible,  but  was  roused  by  a  loud  noise,  and  spoke 
rationally  for  a  minute  or  two,  but  then  relapsed  into  a  state  of 
incoherency.  Pulse  as  yesterday  ;  respiration  oppressed  and  low  ; 
face  and  head  congested  and  blue  ;  discharge  from  the  car  abundant 
and  fetid.     Leeches  were  applied  below  the  ear. 

March  30th. — Slight  relief  followed  the  application  of  the  leeches, 
but  the  patient  soon  grew  rapidly  worse.  The  right  side  of  the 
body  became  paralyzed,  the  breathing  stertorous,  and  the  face  livid. 
Insensibility  gradually  came  on,  and  he  died  at  6  p.m. 

Autopsy,  tivclve  hours  after  death. — With  the  exception  of  a  large 
quantity  of  chocolate-colored  fluid  in  the  lateral  ventricles,  the 
cerebrum  was  healthy,  as  was  also  the  cerebellum.  The  arachnoidal 
surface  of  the  dura  mater,  covering  the  superior  and  mastoid  sur- 
faces of  the  petrous  bone,  was  in  a  healthy  state  ;  but  upon  removing 
it  from  the  bone,  over  two  small  portions  of  both  surfaces,  it  was 
found  to  be  softer  than  natural,  and  these  soft  portions  covered 
apertures  in  the  diseased  bone.  The  appearance  of  disease  was, 
however,  so  slight,  that  it  was  quite  manifest  that  the  affection  of 
the  ear  had  not  made  its  way  inwards  at  either  of  the  two  points. 
On  removing  the  brain,  there  was  evidence  of  very  extensive  disease 
at  its  base.  Purulent  matter  was  deposited  beneath  the  arachnoid, 
from  the  roots  of  the  olfactory  bulbs,  anteriorly,  to  the  medulla  ob- 
longata, posteriorly.     In  some  parts  this  pus  was  of  a  dark  color ; 


NERVOUS    DEAFNESS.  397 

in  others,  as  in  the  pons  Varolii,  the  arachnoid  membrane  was 
ulcerated.  The  principal  seat  of  the  disease  "was  the  right  side  of 
the  pons  Varolii,  the  substance  of  which  was  ulcerated  to  the  depth 
of  a  line  to  a  line  and  a  half,  over  a  surface  as  large  as  a  sixpence. 
All  the  nei'ves,  at  their  origins,  were  surrounded  Avith  pus,  and  the 
substance  of  the  facial  and  auditory  nerves  of  the  right  side  Avas  so 
soft  as  to  be  scarcely  distinguishable  from  purulent  matter.  On 
examining  the  petrous  bone,  the  dura  mater  around  the  orifice  of  the 
meatus  auditorious  internus  Avas  observed  to  be  softened  and  de- 
tached from  the  denuded  bone.  The  portions  of  the  auditory  and 
facial  nerves  Avithin  the  meatus  Avere  also  in  a  state  of  suppuration. 
The  Avhole  of  the  petrous  bone  being  removed  for  the  purpose  of 
careful  dissection,  the  following  was  the  condition  of  the  parts 
detected.  The  external  meatus  contained  tAA'O  polypi,  one  of  Avhich, 
as  large  as  a  small  pea,  A\'as  attached,  by  a  broad  base,  to  the  poste- 
rior wall  of  the  meatus,  about  its  middle ;  the  other,  and  smaller, 
about  the  size  of  a  grape  seed,  was  also  attached  to  the  meatus  near 
the  former.  When  the  membranous  meatus  Avas  separated  from  the 
bone,  there  Avas  found  in  the  latter  an  orifice  between  tAvo  and  three 
lines  in  diameter,  so  that  a  communication  existed  betAveen  the 
meatus  and  the  mastoid  cells ;  there  Avas,  hoAvevcr,  no  orifice  in  the 
membranous  meatus,  and  consequently  the  discharge  from  the  ear 
came  not  from  the  mastoid  cells,  but  from  the  surface  of  the  meatus 
only.  The  membrana  tympani  was  entire,  but  quite  Avhite  and 
much  thicker  than  natural.  The  tympanic  cavity  contained  a  large 
quantity  of  fetid  pus,  and  its  lining  fibro-mucous  membrane  was 
ulcerated  at  several  points.  Within  the  cavity  there  were  also  tAvo 
portions  of  carious  bone,  one  projecting  towards  the  cavity  of  the 
cerebrum  and  in  contact  Avitli  the  outer  surface  of  the  dura  mater ; 
the  other,  looking  towards  the  cavity  of  the  cerebellum  and  also  in 
contact  Avith  the  dura  mater,  Avhich  membrane,  as  before  stated, 
Avas,  at  the  points  referred  to,  thick  and  soft.  The  ossicles  Avere 
present,  and  the  stapes  adhered  Avith  its  usual  degree  of  firmness  to 
the  circumference  of  the  fenestra  ovalis.  On  laying  open  the  cavity 
of  the  vestibule,  it  Avas  found  to  be  full  of  a  dark-colored  pus,  having 
a  fetid  odor;  the  semicircular  canals  were  also  full  of  similar  mat- 
ter, and  the  osseous  Avail  of  the  superior  canal  Avas  carious  at  tAvo  or 
three  points.  This  purulent  matter  extended  from  the  vestibule 
and  cochlea  to  the  meatus  auditorious  internus.  While  carefully 
examining  the  external  semicircular  canal,  Avhere  it  makes  a  bulging 


398 


THE     DISEASES     OF    THE    EAR. 


in  the  tympanic  cavity,  a  small  carious  aperture,  not  larger  than  a 
small  pin's  head,  ^vas  detected  in  it,  which  contained  fetid  pus,  and 
was  the  only  medium  through  ■which  disease  could  have  been  trans- 
mitted from  the  tympanic  cavity  to  the  vestibule. 


Fig.  99. 


Caries  of  the  External  Semicircular  Canal.  A  bristle  is  iilaced  through  the  aperture 
in  the  Semicircular  Canal,  showing  the  conimunieation  between  the  Vestibule  and  the 
Tympanic  Cavity  ;  the  upper  wall  of  the  Tymi)anum  has  been  cut  away. 


I  have  described  this  case  as  one  of  disease  orifrinatinor  in  the 
tympanic  cavity,  and  extending  thence  to  the  vestibide,  inwards, 
and  to  the  meatus,  outwards.  The  grounds  for  my  belief  that  the 
disease  originated  in  the  tympanic  cavity  are  various.  In  the  first 
place,  it  is  very  rare  for  suppuration  to  originate  in  the  labyrinth, 
nor  do  I  recollect  ever  to  have  met  with  a  well-marked  case  of  the 
kind  :  and  had  it,  in  this  instance,  originated  in  the  labyrinth,  it 
would  most  probably  have  produced  death  before  it  reached  the 
tympanum.  In  the  second  place,  the  tympanum  is,  as  has  been 
stated,  a  frequent  seat  of  disease  ;  and  the  presence  of  the  un- 
detached  portions  of  necrosed  bone  indicates  long-standing  disease. 

The  nature  and  progress  of  the  disease  would  appear  to  have  been 
the  following  : — AVhen  it  first  made  its  appearance,  it  was  probably 
one  of  catarrh  of  the  mucous  membrane  ;  the  quantity  of  mucus 
secreted  was  too  large  to  admit  of  its  entire  escape  through  the 
Eustachian  tube  ;  the  membrana  tympani  was  consequently  pressed 


NERVOUS    DEAFNESS.  399 

upon,  and,  instead  of  ulcerating  and  allowing  the  matter  to  escape 
externally,  became  itself  much  thickened  and  very  rigid ;  the  secre- 
tion being  thus  confined  in  the  tympanic  cavity,  produced  caries  of 
the  bone  and  penetrated  the  labyrinth.  There  can,  it  seems  to  me, 
be  no  doubt,  that  had  the  membrana  tympani  been  partially  de- 
stroyed, and  free  egress  been  in  that  way  afforded  to  the  secreted 
matter,  the  disease  in  the  bone  might  have  been  prevented,  and  the 
life  of  the  patient  by  that  means  saved. 

Another  opportunity  Avas  kindly  given  to  me,  by  the  late  Mr. 
Avery,  of  seeing  the  post-mortem,  and  making  a  careful  dissection 
of  the  ear,  in  a  second  case  of  disease  advancing  from  the  tympa- 
num to  the  labyrinth.  In  this  instance,  the  medium  of  communica- 
tion Avas  the  fenestra  ovalis,  Avhich  had  been  left  open  after  the 
removal  of  the  stapes  by  ulceration. 

Ulceration  of  the  tympanic  mucous  membrane;  extension  of  dis- 
ease to  the  labyrinth  through  the  fenestra  ovalis. — James  Warner 
Smith,  aged  17,  a  sailor,  was  admitted  into  the  Charing  Cross  Hos- 
pital, on  the  14th  of  January,  1846.  The  history  of  his  case  was, 
that  at  five  years  of  age  he  had  an  attack  of  measles,  followed  by 
an  abundant  discharge  from  the  left  ear,  from  which  he  has  never 
since  been  perfectly  free,  although  occasionally  the  quantity  was 
very  small.  He  had  usually  enjoyed  good  health.  Three  months 
previously,  Avhen  off  the  Cape  of  Good  Hope,  he  was  up  aloft  during 
a  gale,  and  lost  his  cap.  Great  pain  in  the  ear  followed  this  acci- 
dent, and  the  quantity  of  discharge  increased.  There  have  been 
many  attacks  of  pain  since,  and  occasionally  a  sanguineous  dis- 
charge. When  he  came  on  shore,  he  took  a  fresh  cold,  and  the 
pain  in  the  head  and  ear  became  very  violent.  He  now  consulted 
a  surgeon,  Avho  ordered  him  injections,  drops,  and  ointments  ;  but 
not  obtaining  any  relief,  he  applied  to  Charing  Cross  Hospital.  At 
the  time  of  his  admission,  he  complained  of  constant  pain  in  the  left 
ear,  and  in  the  left  side  of  the  head  as  high  as  the  vertex,  with  a 
certain  degree  of  pain  also  on  the  right  side.  The  muscles  on  the 
right  side  of  the  face  were  constantly  twitching,  and  the  mouth  was 
as  constantly  drawn  to  that  side.  Some  intolerance  of  light  was 
also  observed.  An  abundant  offensive  discharge  proceeded  from 
the  left  ear  ;  but  there  was  no  tenderness  over  the  mastoid  process. 
January  16th. — Has  had  a  violent  paroxysm  of  pain  in  the  night, 
but  is  better  this  morning,  and  the  twitching  has  subsided,  except 
in  the  right  eyelid.     Calomel  and  opium  were  administered. 


400  THE    DISEASES     OF    TUE    EAR. 

January  22(1. — Much  better  ;  slept  well ;  pain  abated. 

January  24th. — Pain  returned  as  violently  as  ever. 

January  27th. — Delirious  during  the  whole  of  the  day. 

January  29th. — Delirium  continues  :  complains  of  intense  pain 
in  both  sides  of  the  head  ;  discharge  from  the  ear  abundant ;  head 
drawn  backwards. 

January  30th. — The  delirium  has  left  him,  but  he  is  exceedingly 
drowsy,  and  is  roused  with  great  difficulty.  The  movements  of 
the  limbs  and  their  sensation  unaifccted.  The  pupils  acted  pro- 
perly. 

February  1st. — The  drowsiness  has  vanished  ;  has  liad  no  deli- 
rium ;  and  has  passed  a  good  night ;  but  still  complains  of  consi- 
derable pain  in  tlie  ear  and  over  the  eyes.  He  remained  in  this 
state  until  the  5th,  when  he  gradually  sank,  without  coma  or 
cerebral  symptoms  of  any  marked  character.  The  retraction  of 
the  head  continued  to  the  last.  He  was  quite  sensible  before  he 
died. 

Autopsy,  tliirty-six  liours  after  death. — On  removing  the  dura 
mater,  the  surface  of  the  arachnoid  was  observed  to  be  remarkably 
dry  ;  the  vessels  of  the  pia  mater  were  more  than  usually  injected 
on  the  convex  surface  of  the  hemispheres  ;  there  were  two  or  three 
small  yellow  patches  beneath  the  arachnoid.  Each  lateral  ventricle 
contained  at  least  three  ounces  of  clear  fluid  ;  in  the  posterior 
corner  of  the  right,  and  in  the  inferior  of  the  left,  Avere  two  patches 
of  bright  yellow  lymph,  as  large  as  half-a-crown,  which  were  covered 
by  a  thick  creamy  purulent  fluid.  The  third  ventricle  contained  a 
dark  clot  of  blood,  of  the  size  of  a  small  walnut,  which  could  be 
traced  into  the  fourth  ventricle,  where  there  was  also  a  small  coagu- 
lum.  The  commissura  mollis  was  broken  down.  Surrounding  the 
lower  part  of  the  commissure  of  the  optic  nerves,  and  covering  the 
pons  Varolii,  crura  cerebri,  medulla  oblongata,  and  upper  part  of 
of  the  medulla  spinalis,  was  a  layer  of  pure  yellow  pus  and  lymph, 
nearly  h;ilf  an  inch  thick  ;  it  embraced  the  nerves  at  the  base  of 
the  brain  to  their  passage  through  their  several  foramina.  The 
parts  in  direct  contact  with  this  layer  were  very  soft.  Under  the 
pia  mater,  where  the  right  anterior  lobe  rests  on  the  orbital  plate 
of  the  frontal  bone,  there  was  a  patch  of  effused  blood,  the  size  of  a 
shilling.  The  dura  mater  covering  each  petrous  bone  was  healthy, 
and  the  exterior  of  the  bone  did  not  present  any  appearance  of  dis- 
ease.    On  examining  the  cavity  of  the  ear,  the  membrana  tympani 


NERVOUS    DEAFNESS.  401 

was  found  to  have  been  destroyed  by  ulceration,  and  all  the  ossicles 
had  disappeared.  The  tympanic  cavity  was  full  of  the  most  offen- 
sive secretion,  and  its  lining  membrane  was  ulcerated.  The  fenestra 
ovalis  was  open,  and,  in  tiic  cavity  of  the  vestibule,  similar  matter 
was  found  to  that  in  the  tympanum.  The  whole  of  the  natural 
membranous  labyrinth  had  been  destroyed.  The  auditory  nerve 
was  tumefied,  and  of  a  dull  livid  color,  the  disease  having  evidently 
advanced  to  it  through  the  cribriform  floor  of  the  internal  aiulitory 
meatus,  and  thence  to  the  base  of  the  brain. 

It  is  to  be  remarked,  that  in  this  case  there  appeared  to  be  no 
obstacle  to  the  free  egress  of  the  matter,  except  the  accinnulation 
of  thick  masses  of  it  in  the  cavity  of  the  tympanum.  It  is  far  from 
improbable  that,  in  cases  of  ulceration  of  the  mucous  membrane  of 
the  tympanum  and  loss  of  the  stapes,  the  thick  secretion  in  the 
tympanum  may  be  quite  sufficient  to  cause  the  disease  to  advance 
inwards.  The  case  is  also  another  illustration  of  the  necessity  there 
exists  for  frequently  washing  out  the  tympanic  cavity  with  Avarm 
water.  It  is,  however,  no  doubt  possible,  ere  the  stapes  is  removed, 
for  the  disease  to  advance  to  the  vestibule  without  the  agency  of  the 
pent-up  matter  in  the  tympanum. 

Besides  the  two  cases  just  described,  I  have  met  with  two  others ; 
and  as  these  four  cases  are  the  only  instances  I  have  found  on  re- 
cord of  this  peculiar  form  of  the  disease,  brief  particulars  of  the  two 
latter  are  subjoiiied. 

The  first  of  these  cases  occurred  in  the  practice  of  Mr.  Streeter, 
and  was  laid  by  him  before  the  Westminster  Medical  Society  on  the 
13th  January,  1844. 

Disease  extending  from  the  tymjianic  cavity  to  the  labyrinth,  and 
thence  to  the  medulla  oblongata  and  the  base  of  tlie  brain. — The 
patient  was  a  lady,  aged  42,  who  had  been  deaf  in  the  right  ear 
since  the  age  of  seven,  but  from  what  cause  Avas  not  known.  Two 
or  three  months  previous  to  her  death,  she  became  affected  with  a 
severe  headache,  for  which  a  blister  was  applied  at  the  back  of  the 
neck.  Nothing  serious,  however,  was  thought  of  the  matter  until 
the  17th  December,  Avheu  the  severity  of  the  pain  so  increased  as  to 
become  of  a  maddening  character,  and  almost  to  produce  delirium. 
The  right  portio  dura  nerve  was  paralyzed,  and  there  was  severe 
pain  doAvn  the  spine,  Avhich  was  attributed  to  a  fall  received  when 
getting  out  of  bed.  The  pulse  did  not  warrant  active  depletion,  but 
two  or  three  leeches  were  applied  behind  the  affected  ear ;  a  large 

26 


402  THE    DISEASES    OF    THE     EAR. 

poultice  was  applied  over  the  face ;  the  ear  was  gently  syringed 
with  warm  water,  and  saline  medicines  were  ordered.  On  the  18th 
she  had  some  sleep  in  the  night,  but  complained  of  an  almost  intoler- 
able pain  in  the  back.  The  catamenia  now  appeared,  and  the  cause 
of  tlie  i)ain  remained  obscure.  She  was  quite  sensible,  the  pupils 
acted,  but  the  cornea  on  the  affected  side  had  begun  to  ulcerate. 
There  was  a  slight  discharge  from  the  right  ear,  and  the  left  had 
become  somewhat  deaf.  It  was  thought  that  a  hole  could  be  ob- 
served in  the  membrana  tympani  :  calomel  and  opium  were  admi- 
nistered. 

December  19th. — She  has  slept  better  and  remained  somewhat 
improved  until  five  or  six  in  the  evening  of  the  21st,  when  she  was 
suddenly  seized  with  coma,  and  continued  in  that  state  until  the 
following  morning,  when  she  died. 

Autopsi/. — On  examining  the  brain,  slight  sub-araclinoid  effusion 
and  vascularity  of  its  surface  were  found,  as  also  some  increase  of 
vascularity  in  the  interior  ;  but  there  was  no  effusion  in  the  ventri- 
cles. An  abscess  was  discovered  in  the  tympanum  and  labyrinth, 
and  there  was  a  counter-abscess,  about  the  size  of  a  large  pea,  in 
the  condensed  araclmoid  and  pia  mater,  occupying  the  fossa  where 
the  facial  and  auditory  nerves  proceed,  from  the  junction  of  the 
medulla  oblongata  with  the  pons  Varolii  and  cerebellum.  Pus  was 
effused  beneath  the  arachnoid  and  pia  mater,  investing  the  right 
side  of  the  upper  portion  of  the  medulla  oblongata,  and  the  adjoin- 
ing part  of  the  right  lobe  of  the  cerebellum,  to  about  the  extent  of  a 
square  inch  ;  but  there  was  neither  softening  nor  apparent  lesion  of 
the  proper  cerebral  tissue  beneath. 

The  exact  condition  of  the  tympanic  cavity  and  labyrinth  is  not 
detailed  in  the  al)Ove  notes  by  Mr.  Streeter ;  but  there  can  be  no 
doubt  that  tlie  disease  (most  probably  ulceration  of  the  mucous 
membrane)  had  extended  from  the  tympanum  to  the  vestibule, 
either  through  the  fenestra  rotunda  or  ovalis,  or  by  means  of  an 
orifice  in  the  osseous  wall  of  the  labyrinth.  The  state  of  the  portio 
dura  and  portio  mollis  nerves  is  not  stated;  but  judging  from  the 
records  of  other  cases  of  a  similar  character  to  the  present,  these 
nerves  must  have  undergone  some  morbid  change  and  communicated 
the  disease  to  the  base  of  the  brain. 

Tbe   remaining  case  is  taken  from  M.   Itards  work,'  and  is  as 

'  Trnite  des  Maladies  de  I'Oreille.  1821.     Tome  i,  p.  254,  Obs.  22. 


NERVOUS     DEAFNESS.  403 

follows :  A  man,  aged  22,  five  weeks  before  his  death,  complained 
of  toothache:  this  was  followed  by  febrile  symptoms.  On  the 
twelfth  day  after  the  attack,  discharge  took  place  from  the  left  ear, 
but  symptoms  of  cerebral  irritation  increased  until  lii.s  death. 

Autojjsy. — Over  the  convex  surface  of  the  brain,  and  in  its  sub- 
stance, were  a  number  of  small  purulent  deposits.  The  cerebellum 
was  similarly  affected,  but  in  a  less  degree.  The  auditory  and  facial 
nerves  were  in  a  state  of  suppuration,  and  almost  wholly  destroyed  : 
pus  was  also  found  in  the  internal  auditory  meatus,  the  vestibule, 
cochlea,  and  semicircular  canals,  and  the  tympanic  cavity. 

The  treatment  to  be  pursued  in  these  cases  is  similar  to  that 
recommended  in  cases  of  disease  of  the  tympanum  and  the  mastoid 
cells. 


CHAPTER    XVII. 

MALIGNANT  DISEASE  OF  THE  EAR. 

ORIGIN  IN  THE  MCCOCS  MKMBRANE  OF  THE  TYMPANUM — DESTRUCTION  OF  THE  PETROUS 
BONE — SOMETIMES  MISTAKEN  FOR  POLYPUS — OPERATIONS  TO  BE  AVOIDED — BRAIN 
AND    DURA    MATEU    INVOLVED — TREATMENT. 

Cases  of  malignant  disease,  advancing  from  the  ear  towards  the 
brain,  appear  to  be  of  rare  occurrence.  So  far  as  my  own  expe- 
rience and  tlie  aid  of  published  cases  permit  me  to  judge,  it  appears 
most  probable  that  the  part  of  the  ear  in  which  malignant  disease 
usually  originates,  is  the  mucous  membrane  lining  the  cavity  of  the 
tympanum.  After  the  diseased  growth  has  destroyed  the  merabrana 
tyuipani,  it  advances  through  the  external  meatus  to  the  outer  orifice, 
where  it  shows  itself  in  the  shape  of  a  small  tumor,  Avhich  has 
sometimes  been  mistaken  for  a  polypus,  and  the  removal  of  which 
has  caused  hemorrhage  and  an  aggravation  of  the  symptoms.  At 
the  same  time  that  the  disease  advances  outwards,  it  also  encroaches 
upon  the  whole  of  the  parts  surrounding  the  organ  of  hearing.  The 
osseous  walls  of  the  meatus  externus  and  of  the  tympanic  cavity  are 
wholly  destroyed  ;  the  outer  part,  and  even  the  whole  of  the  petrous 
bone,  are  converted  into  a  mass  of  disease ;  the  lower  part  of  the 
squamous  bone  also  disappears,  and  the  tumor  ailvanccs  into  the 
cavity  of  the  skull,  where  it  destroys  life,  cither  by  its  pressure  upon 
the  brain  or  its  bloodvessels,  or  by  involving  the  brain  itself  in  the 
disease. 

This  malignant  disease  is  sometimes  of  the  nature  of  fungus 
hsematodes ;  at  other  times  it  has  the  characters  of  encephaloid 
disease.  This  affection  occurs  at  various  periods  of  life:  the  ages 
of  the  three  patients  to  whose  cases  reference  is  about  to  be  made, 
were  respectively  3,  18,  and  35 ;  the  progress  is  very  rapid  gene- 
rally,   and  forms  a  marked   contrast   with   those  cases  of  chronic 


MALIGNANT     DISEASE    OF    THE     EAR.  405 

disease  of  the  ear  advancing  to  the  brain,  to  which  attention  has 
hitherto  been  drawn. 

Sophia  W.,  aged  35,  a  single  woman,  was  admitted  under  my  care 
into  St.  Mary's  Hospital,  on  the  14th  July,  1854,  The  history,  as 
given  by  herself,  is,  that  after  a  severe  cold,  a  year  previously,  the 
right  ear  suddenly  became  painful,  though  the  pain  was  not  very 
severe.  Since  the  above  period,  the  pain  has  been  gradually  in- 
creasing, accompanied  by  a  tumefxction  of  the  right  side  of  the  face. 
Six  months  ago  a  red  growth  Avas  removed  from  the  tube  of  the  ear, 
which  the  surgeon  considered  to  be  a  polypus,  and  since  then  she 
has  had  at  times  a  good  deal  of  bleeding  from  the  ear.  Lately  the 
pain  has  greatly  increased,  and  has  extended  over  the  side  of  the 
head  and  the  face ;  a  small  round  swelling  has  also  appeared  at  the 
orifice  of  the  ear.  On  examination,  the  external  ear  was  observed 
to  be  much  redder  than  natural,  and  somewhat  hypertrophied ;  and 
the  orifice  of  the  meatus  was  closed  by  a  red  tumor,  about  the  size 
of  an  almond,  upon  pressing  one  side  of  which  a  small  quantity  of 
sanious  discharge  issued  from  the  meatus.  The  inteo;uments  around 
the  ear,  for  the  distance  of  an  inch  and  a  half,  were  red,  soft,  and 
somewhat  elevated  above  the  surrounding  parts  by  a  tumor  beneath 
them.  The  left  portio  dura  nerve  Avas  completely  paralyzed  ;  there 
was  much  pain  of  a  pricking  and  shooting  character  complained  of 
in  the  region  of  the  tumor,  and  this  at  times  extended  inwards  to 
the  brain.  The  treatment  consisted  in  occasional'y  applying  a  leech 
or  two  in  the  region  of  the  ear,  so  as  by  diminishing  the  congestion, 
to  relieve  the  pain ;  small  doses  of  morphia  were  frequently  admin- 
istered, and  the  general  health  supported  ;  the  meatus  was  frequently 
syringed  with  warm  water,  and  emollient  applications  made  to  the 
tumor.  These  remedies,  however,  led  to  very  transient  amelioration 
of  the  symptoms ;  though  the  pain  would  sometimes  subside,  the 
patient  was  subject  to  frequent  and  severe  relapses.  She  was  able, 
however,  to  walk  about  the  ward,  and  a  few  days  previous  to  her 
death  expressed  a  wish  to  leave  the  hospital  in  order  to  visit  her 
friends  in  the  country.  On  the  23d  of  October,  she  did  not  com- 
plain more  than  usual  of  the  pain  in  the  face  and  head,  but  on  the 
24th  and  25th  there  were  symptoms  of  considerable  cerebral  conges- 
tion, she  Avandered  a  good  deal,  and  the  head  was  evidently  a  source 
of  great  distress  to  her.  The  symptoms  of  congestion  gradually  in- 
creased, and  she  died  on  the  28th  of  October. 

Autopsy. — The  integuments  of  the  external  ear,  and  those  cover- 


406  THE     DISEASES     OF     THE     EAR. 

ing  the  tumor,  ■were  red  and  tumefied.  Upon  reflecting  the  ear  and 
the  integuments  from  the  tumor,  a  large  mass  was  exposed,  Avliich 
extended  from  the  posterior  part  of  the  mastoid  process,  posteriorly, 
to  the  body  of  the  malar  bone  anteriorly,  and  also  from  half  an  inch 
below  the  squamous  suture  to  the  angle  of  the  inferior  maxilla 
below.  The  tumor  was  intimately  connected  with  the  integuments, 
and  of  a  reddish-white  color.  It  presented  different  degrees  of  con- 
sistence, being  in  front,  where  it  surrounded  the  ascending  ramus  of 
the  lower  maxilla,  quite  hard  and  firm  like  the  pancreas,  while  more 
posteriorly  it  was  softer ;  and  deeper  towards  the  styloid  process, 
there  was  a  large  quantity  of  a  white  creamy  fluid.  Both  anterior 
and  posterior  to  the  external  auditory  meatus,  the  tumor  contained 
small  spicuUx!  of  bone.  The  mastoid  process  was  involved  in  the 
disease,  and  Avas  deduced  to  some  detached  masses  of  bone  in  the 
middle  of  a  portion  of  the  tumor.  The  osseous  meatus  had  wholly 
disappeared,  and  the  remains  of  the ,  membranous  meatus  could 
scarcely  be  distinguished,  its  walls  having  become  so  much  involved 
in  the  diseased  mass.  The  only  remains  of  the  tympanic  cavity 
were  some  portions  of  the  mucous  membrane,  having  a  dark  livid 
hue,  with  distended  bloodvessels,  and  small  red  growths  attached  to 
it.  Not  a  remnant  was  left  of  the  bony  cavity.  The  whole  of  the 
squamous  bone,  from  an  inch  below  the  squamous  suture,  and  the 
whole  of  the  outer  part  of  the  petrous  bone  had  been  destroyed,  so 
that  the  apex  of  the  petrous  bone  had  no  connection  with  the  squa- 
mous. The  tumor  had  advanced  inwards  to  the  cavities  of  the 
cerebrum  and  cerebellum,  through  the  aperture  formed  by  the 
destruction  of  the  squamous  and  petrous  bones.  In  the  middle 
cerebral  fossa  was  a  reddish-white  tumor,  of  about  the  size  of  a  small 
pear,  which  consisted  of  two  portions,  one  below,  and  the  other 
above,  the  dura  mater.  The  part  below  the  dura  mater  was  directly 
continuous  with  the  external  tumor,  while  the  large  portion  above 
seemed  to  be  an  indejjendent  growth  from  the  free  surface  of  the 
dura  mater,  and  connected  to  the  larger  mass  of  the  tumor  by 
bloodvessels  only.  The  upper  part  of  this  portion  of  the  tumor 
was  adherent  to  the  lower  surfiice  of  the  left  middle  cerebral  lobe, 
which  was  softened  to  the  depth  of  half  an  inch.  The  part  of  the 
tumor  posterior  to  the  petrous  bone,  and  beneath  the  tentorium,  was 
somewhat  smaller  and  less  prominent  than  that  just  described  in  the 
middle  cerebral  fossa,  was  wholly  confined  to  the  interior  surface  of 
the  dura  mater,  and  must  have  almost  entirely  arrested  the  circula- 


MALIGNANT    DISEASE    OF    TUB     EAR.  407 

tion  of  tlie  lateral  sinus.  The  Avholc  of  the  cerehral  veins  and 
sinuses  were  very  much  distentled  with  dark-colored  blood,  but 
there  was  no  appearance  of  disease  in  any  other  part  of  the  cerebral 
substance  than  the  softened  portion  of  the  inferior  lobe. 

On  examining  the  tumor  by  the  aid  of  the  microscope,  the  harder 
portions  were  found  to  consist  of  very  delicate  fibres  and  nucleated 
cells,  Avhile  the  softer  parts  and  creamy  fluid  were  almost  wholly 
composed  of  nucleated  cells,  circular,  fusiform,  and  angular. 

There  appears  every  reason  to  believe  that,  in  this  case,  the  dis- 
ease originated  in  the  tympanic  cavity.  It  will  have  been  seen  that 
the  seat  of  the  pain  when  first  complained  of,  was  the  car.  This 
was  followed  by  a  growth  from  the  meatus,  similar  to  a  polypus,  and 
then  by  paralysis  of  the  portio  dura  nerve.  From  this  centre  the 
disease  seems  to  have  spread  in  all  directions,  destroying  every 
structure  which  it  approached.  In  the  preparation,  a  large  portion 
of  the  osseous  Avail  of  the  cranium  is  seen  to  be  absent,  so  that,  by 
pressing  upon  the  tumor  during  life,  the  contents  of  the  cerebral 
cavity  were  also  subject  to  pressure.  Unfortunately  in  these  cases, 
little  can  be  done  even  to  alleviate  the  sufferings  of  the  patient. 
Local  depiction  by  leeches  applied  to  the  vicinity  of  the  tumor,  hot 
fomentations  and  the  administration  of  opiates,  appear  to  be  the 
only  remedies  capable  of  doing  any  service.  It  is  nevertheless  of 
the  utmost  importance  to  be  able  to  decide  upon  the  nature  of  the 
disease  whenever  it  does  occur,  since  measures  Avill  at  least  be  re- 
frained from  that  are  calculated  to  aggravate  the  disease,  and  no 
operation  Avill  be  attempted.  In  the  case  in  question,  it  is  possible 
that  the  removal  of  part  of  the  tumor,  which  was  thought  to  be 
a  polypus,  did  material  injury,  by  causing  the  disease  to  advance 
more  rapidly.  Those  Avho  are  careful  will  have  no  difiiculty  in  dis- 
tinguishing between  an  ordinary  polypus  growing  from  the  walls  of 
the  meatus,  and  a  portion  of  tumor  similar  to  that  of  the  case  under 
discussion.  The  polypus  is  smooth  and  globular,  and  not  covered 
by  epidermis  ;  neither  does  it  present  an  ulcerated  surface,  such  as 
Avould  be  disclosed  by  a  portion  of  encephaloid  tumor  when  it  exists 
and  gives  off  secretion.  Again,  in  cases  of  polypus  growing  from 
the  external  meatus,  there  is  very  rarely  any  tumefaction  of  the 
ear  or  integuments,  such  as  is  found  in  malignant  disease.  The  ob- 
servation, so  frequently  made  by  me,  may  here  be  repeated,  that  as 
polypoid  growths  are  so  often  symptomatic  of  the  existence  of  irri- 
tation within  the  tympanic  cavity,  aiul  are  sometimes  coexistent 


408  THE     DISEASES     OF     THE     EAR. 

with  disease  of  the  bone,  great  caution  shouUl  always  be  used  pre- 
vious to  ])roceeding  to  extirpation.  By  referring  to  a  very  interest- 
ing case  of  malignant  disease  of  the  ear,  published  by  Mr.  AVilde  at 
page  20G  of  his  treatise  on  Aural  Surgery,  it  will  be  found  that  he 
also  lays  much  stress  upon  the  necessity  of  being  careful  "  in  med- 
dling with  morbid  growths  of  long  standing,  without  being  fully 
satisfied  as  to  their  nature,  and  the  place  from  which  they  grow." 
The  cause  of  death  in  the  patient  whose  case  has  here  been  con- 
sidered, appears  to  have  been  congestion  of  the  brain,  produced  by 
the  pressure  of  the  tumor  on  its  substance,  as  well  as  upon  the 
lateral  sinus. 

The  second  preparation  illustrative  of  the  effects  of  malignant 
disease  of  the  ear  extending  to  the  brain,  Avhich  has  to  be  described, 
was  laid  before  the  Pathological  Society  of  London,  in  1850,  by 
Mr.  Cooper  Forster,  to  whom  I  am  indebted  for  the  specimen.  The 
particulars,  copied  from  the  Transactions  of  the  Pathological  So- 
ciety, are  as  follow  : — 

"•  A  strumous  lad,  aged  19,  was  knocked  down  by  a  cab  nineteen 
months  before  his  death,  and  struck  on  the  right  side  of  his  head. 
He  soon  afterwards  became  deaf,  and  suffered  severe  pain  in  the 
right  ear  ;  the  part  became  slightly  swollen  and  excessively  tender, 
especially  over  the  mastoid  process.  The  swelling  did  not  increase, 
but  the  pain  in  the  head  was  most  intense,  and  paralysis  of  the 
right  portio  dura  nerve  took  place.  No  great  change  occurred  until 
within  the  last  six  months,  when,  from  another  blow  on  the  same 
spot,  the  disease  seemed  to  become  more  active  ;  the  side  of  the 
head,  from  above  the  temporal  ridge  to  two  inches  below  the  ear, 
became  enormously  enlarged  and  tender ;  and  the  external  ear  ap- 
peared as  though  pushed  away  from  the  side  of  the  head.  He  ex- 
perienced great  difficulty  in  swallowing  solid  food,  and  was  also 
unable  to  speak. 

"  About  two  months  before  his  death,  the  swelling  began  to  fun- 
gate  and  slough,  profuse  hemorrhage  occurred  at  intervals,  and 
sloughing  very  rapidly  took  })lace,  and  at  last  laid  bare  the  pharynx. 
To  such  an  extent,  ultimately,  had  the  destructive  action  taken 
place,  that  a  large  chasm  formed  around  the  ear,  leaving  that  organ 
completely  isolated.  Xo  brain  symptoms  occurred.  The  profuse 
hemorrhage  and  constant  drain  of  pus  (juickly  destroyed  him. 

^''Autopsy. — The  brain  appeared  perfectly  healthy  except  at  the 
lower  part  of  the  right  hemisphere,  wliich  was  pulpy  and  very  soft. 


MALIGNANT    DISEASE     OF    THE    EAR. 


409 


The  softening  was,  without  doubt,  occasioned  by  the  upward  pres- 
sure of  a  hard  scrofulous-looking  mass,  attached  to  the  petrous 
portion  of  the  temporal  bone,  through  the  intei'vention  of  the  dura 
mater,  from  which  it  seemed  to  spring.  The  mass  pressed  upon  the 
bone  below,  and  appeared  as  though  inclined  to  force  its  way  down- 
wards, through  the  temporal  bone,  at  the  junction  of  the  squamous 
Avith  the  petrous  portion,  a  great  part  of  the  latter  being  completely 
absorbed.  Some  new  bone  had  formed  at  the  inner  side,  and  the 
whole  of  the  exterior  was  occupied  by  a  sloughy  nwss  and  carious 
bone  (as  seen  below),  the  surrounding  parts  being  very  hypertrophied ; 
no  vestige  of  meatus  or  mastoid  cells  could  be  discovered  ;  the  lateral 
sinus  was  filled  by  a  coagulum." 

Fig.  ion. 


^-1:; 


From  the  history  of  the  case  just  cited,  and  an  examination  of 
the  preparation,  there  is  no  doubt  on  my  mind  but  that  the  nature 
of  the  disease  was  malignant,  very  probably  encephaloid,  and  that 
it  commenced  in  the  tympanic  cavity.  It  will  have  been  observed, 
that  the  early  symptoms  indicated  that  the  disease  was  in  the  ear, 
both  by  the  pain  experienced  there,  and  by  the  presence  of  deaf- 
ness.    If  the  preparation  be  carefully  inspected,  it  Avill  be  seen  that 


410  THE    DISEASES    OF    THE    EAR. 

the  largest  amount  of  destruction,  and  the  most  marked  appearance 
of  disease,  are  around  the  tympanic  cavity  ;  from  which  the  progress 
seems  to  have  been  downwards  to  the  pharynx,  upwards  to  the 
outer  surface  of  the  squamous  bone,  and  histly,  inAvards  and  up- 
wards to  the  cavity  of  the  skull.  The  orifice  communicating  between 
the  disease  without  and  that  within,  is,  however,  very  small  in  com- 
parison to  the  extent  of  the  disease  externally,  and  the  internal 
surface  of  the  bone  is  much  less  affected  than  the  outer.  That  the 
disease  was  malignant  is  shown,  I  think,  by  the  bleeding  and  fungoid 
character  of  the  soft  growth,  and  tlie  peculiar  expanded  and  spicu- 
lated  state  of  the  bone. 

The  third  case  is  one  published  in  the  eleventh  volume  of  the 
Edinburgh  Medical  and  Surgical  Journal,  by  Mr.  Wishart,  and 
called  by  him  a  case  of  fungus  hfcmatodes.  The  subject  was  a  child 
three  years  old,  in  whom,  after  suffering  for  some  weeks  from  severe 
pain  in  the  right  ear,  followed  by  discharge,  a  tumor  appeared 
surrounding  the  ear,  and  which  speedily  ulcerated,  discharging  a 
large  quantity  of  fetid  bloody  matter  ;  hemorrhage  also  fre(|uently 
occurred.  The  child  died  within  fifteen  weeks  after  the  appearance 
of  the  disease.  On  a  post-mortem  examination,  the  tumor  was 
found  to  be  as  large  as  the  child's  head ;  externally  it  had  caused 
the  destruction  of  the  condyloid  process  of  the  lower  jaw ;  the 
zygomatic  process  was  also  gone.  The  tumor  had  advanced  inwards, 
destroying  the  whole  of  the  petrous  bone,  and  extended  upwards, 
through  a  large  orifice  in  the  squamous  bone,  so  as  to  form  a  de- 
pression on  the  middle  lobe  of  the  brain,  which  was  in  other  respects 
quite  sound. 

As  bearing  upon  the  subjent,  I  may  as  well  give  briefly  the  par- 
ticulars of  a  case  of  disease  of  the  petrous  bone  which  occurred  in 
the  practice  of  Mr.  Part,  of  Camden  Town,  to  whom  I  am  indebted 
for  the  preparation.  The  patient  was  a  clergyman,  aged  twenty- 
five,  subject  for  five  years  to  a  discharge  from  the  right  ear,  with 
occasional  pain.  A  year  before  his  death  an  abscess  broke  behind 
the  ear,  wliich  discharged  at  times.  About  a  fortnight  before  his 
death  he  suftercd  from  severe  pain  in  the  head  and  vomiting,  and 
had  paralysis  of  tlie  right  ])ortio  dura  nerve.  lie  was  not  relieved 
by  Jvny  treatment,  and  the  head-symptoms  increased  until  his  death. 
On  a  post-mortem  inspection,  a  cavity  was  found  in  front  of  the  ear, 
and  another  beneath  the  temporal  muscles ;  both  contained  a  soft 
caseous  substance.     Tlie  whole  of  the  petrous  bone,  a  portion  of  the 


MALIGNANT     DISEASE    OF    THE     EAR.  411 

basilar  process  of  the  occipital  and  of  the  sphenoid,  were  found  de- 
generated into  a  soft  cheesy  mass.  The  malar  bone  was  destroyed, 
and  the  mastoid  process  occupied  by  the  disease.  The  ventricles 
contained  three  ounces  of  bloody  serum ;  the  arachnoid  was  much 
injected ;  while  between  it  and  the  pia  mater  was  a  layer  of  very 
yellow  pus,  extending  along  the  base  of  the  brain.  In  the  middle 
lobe  of  the  brain  was  an  abscess  containing  upwards  of  an  ounce  of 
very  fetid  greenish  pus ;  and  a  second  abscess  existed  in  the  middle 
of  the  posterior  lobe.  If  the  preparation  be  examined,  as  in  the 
preceding  cases,  there  will  be  found  to  be  a  large  aperture  in  the 
squamous  bone,  and  the  petrous  and  mastoid  bones  are  wholly  con- 
verted into  the  white  cheesy-looking  matter.  On  examination  by 
the  microscope,  this  matter  is  discovered  to  consist  of  cells,  varying 
in  form,  only  few  of  which  have  any  distinct  nuclei ;  granular 
matter  is  also  interspersed  among  the  cells.  The  case  may  be  con- 
sidered as  one  of  degeneration  of  the  petrous  bone,  originating  in 
the  tympanic  cavity. 

The  ulceration  at  times  proceeds  most  rapidly,  extending  to  the 
bone,  which  is  soon  destroyed.  Sometimes  the  greater  part  of  the 
squamous  bone  disappears.  A  case  of  the  kind  has  been  published 
by  Dr.  Russell,  of  Birmingham,  in  the  Association  Journal,  for  March 
31st,  1852,  of  which  I  will  give  a  few  particulars. 

Mrs.  P.,  aged  66,  was  attacked,  about  nine  months  before  her  de- 
cease, Avith  pain  in  the  right  ear,  attended  with  swelling.  A  fort- 
night afterAvards,  she  struck  it  against  a  bracket ;  the  swelling  broke, 
and  the  ear  discharged.  The  discharge  and  pain  continued,  and 
paralysis  of  the  portio  dura  ensued,  while  the  power  of  hearing  dis- 
appeared. xVt  the  time  she  was  seen  by  Dr.  Russell,  there  was  in- 
tense pain  in  the  ear ;  mania,  coma,  and  ultimately  death,  ensued. 
There  was  no  history  of  early  disease  in  the  ear,  but  she  had  been 
accustomed  to  pick  it  with  a  pin,  for  a  certain  degree  of  itching.  On 
an  autopsy,  tlie  entire  S(|uamous  portion  of  the  temporal  bone  was 
found  to  have  been  destroyed,  and  tlic  disease  had  encroached 
upon  the  mastoid  process,  laying  open  the  cells.  Tlu  petrous 
bone  was  also  almost  entirely  destroyed.  The  dura  mater  was  not 
injured,  except  in  one  spot,  where  there  was  a  sloughy  opening,  the 
size  of  a  crown-piece.  Opposite  the  orifice  in  the  dura  mater,  the 
brain  was  in  a  state  of  suppuration ;  and  both  ventricles  were  full 
of  the  ddbris  of  sloughy  cerebral  tissue.  There  were  about  two 
drachms  of  thin,  purulent  fluid  at  the  base  of  the  brain.     This  spe- 


412  THE    DISEASES    OF    THE    EAR. 

cimen,  which  through  the  kindness  of  Dr.  Russell  I  had  an  oppor- 
tunity of  inspecting,  presented  a  very  similar  appearance  to  the  one 
previously  described.  In  each  case  all  vestiges  of  the  tympanic 
cavity  had  disappeared.  They  differ  from  the  great  majority  of 
cases  of  disease  in  the  tympanum,  in  extending  outwards  instead  of 
upwards. 

The  treatment  in  these  cases  consists  in  diminishing  the  symptoms 
of  congestion  of  the  brain,  by  the  occasional  application  of  leeches, 
and  in  attempting  to  allay  the  pain  by  the  administration  of  mor- 
phia. 


CHAPTER   XVIII. 

ON    THE    DEAF    AND    DUMB. 

DISEASES  PRODUCING  DEAF-MUTISM — THE  CONDITION  OF  THE  EARS  IN  THE  DEAF  AND 
DUMB,  AS  ASCERTAINED  BY  EXAMINATION  DURING  LIFE  —  THE  CONDITION  OF  THE 
EAR  IN  THE  DEAF  AND  DUMB,  AS  REVEALED  BY  DISSECTION — THE  MODE  OF  EXA- 
MINING   A    CHILD     SUPPOSED    TO    BE    DEAF    AND     DUMB ON   THE    MEDICAL    TREATMENT 

OF  THE  EARS  OF  THE  DEAF  AND  DUMB — THE  AMOUNT  OF  HEARING  POSSESSED  BY 
CHILDREN  USUALLY  ACCOUNTED  DEAF  AiND  DUMB  —  ON  THE  EDUCATION  OF  THE 
DEAF    AND    DUMB;    WITH    CASES. 

TuE  number  of  deaf-mute  children  examined,  and  from  whom 
the  facts  in  this  chapter  were  obtained,  amounted  to  411.  Of  these, 
313  were  congenital  cases,  and  98  were  the  eflfect  of  different  dis- 
eases acquired  subsequent  to  birth. 


I.    THE    DISEASES    PRODUCING    DEAF-MUTISM. 

On  the  causes  producing  congenital  deaf-mutism  I  am  unable  to 
oifer  a  decided  opinion  ;  but  the  results  of  dissection,  as  detailed  in 
a  subsequent  part  of  this  chapter,  show  that  the  nervous  apparatus 
is  very  frequently  affected.  If  regard  be  also  paid  to  the  other 
cases  I  shall  refer  to,  and  the  non-appearance  of  an  efficient  cause 
of  any  other  kind,  together  with  the  analogy  to  be  drawn  from  the 
cases  in  the  chapter  on  Nervous  Deafness,  it  would  be  no  very 
violent  assumption  to  suppose  that  early  derangement  of  the  nervous 
apparatus  is  at  the  root  of  most  of  the  instances  of  deaf-mutism. 

Of  the  causes  of  acquired  deaf-mutisra  a  more  accurate  estimate 
may  be  formed.  Thus  in  the  98  cases  of  acquired  deafness  the 
causes  were  as  follows  : — 

Scarlet  Fever 30 

Fever, 23 

Measles,   .............  4 

Various  diseases,  as  teething,  convulsions,  hydrocephalus,  a  full,  fits,  a 

fright,  Ac, 35 

98 


414  THE    DISEASES    OF    THE    EAR. 


II.    THE   CONDITION    OF   THE    EARS    IN    THE    DEAF    AND    DUMB,    AS 
ASCERTAINED    BY    EXAMINATION    DURING    LIFE. 

The  condition  of  the  ears  in  the  deaf  and  dumb  is  very  various, 
and  in  the  majority  of  the  ears  there  is  some  abnormal  appearance, 
although  it  is  often  very  slight.  Thus,  in  only  197  out  of  411 
patients  were  the  ears  healthy.  The  following  table  shows  the  con- 
dition of  those  ears  that  were  not  healthy: — 

In  GQ  the  surface  of  the  membrana  tympani  was  dull. 
38  the  membrana  tympani  was  opaque. 
12  the  membrana  tympani  was  more  concave  than  natural. 
3  the  membrana  tympani  was  very  concave  and  opaque. 

1  the  membrana  tympani  was  shrivelled. 

10  the  mem])rana  tympani  had  fallen  inwards. 

9  the  membrana  tympani  was  perforated. 
18  the  membrana  tympani  was  absent,  from  ulceration. 

2  the  meatus  was  full  of  cerumen. 

35  the  meatus  was  full  of  cerumen,  and  the  membrana  tympani 
opaque. 

3  the  meatus  externus  formed  a  cul-de-sac  half  an  inch  from  the 

orifice. 

1  the  meatus  contained  a  polypus. 

3  the  membrana   tympani  of  one  ear  was  opaque,  and  in   the 
other  it  had  fallen  inwards. 

2  the  membrana  tympani  was  opaque  in  one  car  and  absent  in 

the  other. 
1  the  membrana  tympani  was  normal  in  one  ear  and  absent  in 
the  other. 

3  the  membrana  tympani  was  fallen  in  in  one  car  and  perforated 

in  the  other. 
1  the  membrana  tympani  was  natural  in  one  ear  and  the  meatus 

full  of  cerumen  in  the  other. 
1  the  meml)rana  tympani  was  fallen  in  in  one  car  and  dull  in 

the  other. 
1  the  membrana  tympani  was  absent  in  one  ear  and  the  meatus 

contained  a  polypus  in  the  other. 
1  the  membrana  tympani  was  very  concave  in  one  ear  and  had 

fallen  inwards  in  the  other. 


ON    THE    DEAF    AND     DUMB.  415 

In  1  the  membrana  tympani  was  natural  in  one  ear  and  very  con- 
cave in  the  other. 

1  the  memhrana  tympani  was  perforated  in  one  ear  and  opaque 
in  the  other. 

1  the  membrana  tympani  was  very  concave  in  one  ear  and  absent 
in  the  other. 

It  is  interestinjr  to  observe  the  difference  between  the  condition 
of  the  ears  in  the  acquired  and  congenital  cases. 

The  condition  of  the  ears  in  the  313  congenital  cases : — 

172,  or  nearly  three-fifths,  had  a  natural  appearance. 

In  the  172  cases  of  absolute  deafness  the  folloAving  was  the  con- 
dition of  the  ears  : — 

96  had  a  healthy  appearance. 
In  37  each  membrana  tympani  was  dull. 

20  there  was  an  accumulation  of  cerumen,  and  each  membrana 

tympani  Avas  dull. 
12  each  membrana  tympani  was  opaque. 

1  each  membrana  tympani  had  been  destroyed  by  ulceration. 

2  one  membrana  tympani  was  opaque,  the  other  had  fallen  in. 
1  one  membrana  tympani  Avas  opaque,  the  other  Avas  absent. 

1  one  membrana  tympani  Avas  natural,  the  other  Avas  opaque. 
1  one  membrana  tympani  was  natural  and  the  other  was  absent. 
1  one  membrana  tympani  Avas  fallen  in  and  the  other  was  per- 
forated. 


172 


The  following  was  the  condition  of  the  ears  in  the  141  congenital 
cases,  in  Avhich  certain  sounds  Avere  heard : — 

[a.)  In  11  Avho  heard  a  clapping  of  the  hands,  7  had  a  normal 
aspect. 
In  2  each  membrana  tympani  Avas  opaque. 

1  each  meatus  was  distended  by  cerumen,  and  the  membrana 

tympani  Avas  opaque. 
1  each  membrana  tympani  Avas  concave. 


416  THE     DISEASES     OF    THE    EAR. 

(6.)  In  the  44  who  heard  a  shout : — 

21  "vvere  apparently  natural. 
In  7  each  inembrana  tympani  ■was  dull. 

4     "  "  "  "  and  the   meatus    full    of 

cerumen. 
4     "  "  "  opaque. 

4  "  "  "  concave 

2     "  "  "  concave  and  opaque. 

2  "  "  "  perforated. 

(('.)  In  the  30  -who  heard  a  loud  voice : — 

24  were  apparently  normal. 
In  7  each  membrana  tympani  was  dull. 

3  "  "  "  "  and    the   meatus   full  of 

cerumen. 
3     "  "  "  opaque. 

1     "  "  "  concave. 

1  in  one  car  the  membrana  tympani  was  normal ;  in  the  other 
it  was  opaque,  and  the  meatus  full  of  cerumen. 

((?.)  In  the  43  who  heard  the  vowels  and  repeated  them  after 
me: — 

24  appeared  to  be  normal. 
In  G  each  membrana  tympani  was  dull. 

5  "  "  "  "         and  the  meatus  was  full  of 

cerumen. 
5     "  "  "  opaque. 

1  "  "  "  concave  and  opaque. 

(r.)  In  the  5  who  heard  words  and  repeated  them: — 

2  appeared  normal. 

In  1  each  membrana  tympani  was  dull. 

1     "  "  "  "         and  the  meatus  was  full  of 

cerumen. 
1  in  one  ear  the  membrana  tympani  was  opaque  and  concave, 

an<l  in  tlio  other  it  had  fallen  in  towards  the  promontory. 

(/.)  In  the  single  instance  in  wliieh  short  sentences  were  heard 
and  repeated,  the  membrana  tympani  was  dull. 


ON    THE    DEAF    AND     DUMB.  417 


The  condition  of  the  ear  in  the  98  acquired  cases  of  deafness. 

Of  the  entire  number,  only  23,  or  about  one-fourth,  had  a  natural 
appearance ;  of  the  75  cases  of  acquired  deafness,  in  which  there 
Avas  no  power  of  hearing,  19,  or  about  one-quarter,  Avere  apparently 
normal ;  including  those  instances  in  which  the  surface  of  the  mem- 
brana  tvmpani  was  only  slightly  dull,  27,  or  about  one-third  of  the 
whole,  had  a  natural  appearance.  Of  the  25  acquired  cases  in  which 
there  was  a  certain  amount  of  hearing  power,  5,  or  one-fifth,  were 
apparently  healthy. 


Scarlet  Fever. 

In  the  36  cases  of  scarlet  fever,  only  two  patients  had  the  ears  in 
a  healthy  state ;  in  15  each  mcmbrana  tympani  was  absent,  and  in 
5  each  membrana  tympani  was  perforated ;  in  3  each  meatus  formed 
a  cul-de-sac  about  half  an  inch  from  the  orifice.  It  is  clear,  there- 
fore, that  in  the  majority  of  cases  of  deafness  from  scarlet  fever,  the 
effects  of  very  active  disease  were  apparent ;  this  disease  was  usually 
catarrhal  inflammation  of  the  tympanic  mucous  membrane,  ending  in 
an  ulceration  of  that  membrane,  which  extended  to  the  labyrinth. 
As  it  is  interesting;  to  observe  the  relation  between  the  amount  of 
hearing  possessed  by  a  patient,  and  the  condition  of  the  ears,  I  have 
arranged  the  results  in  the  following  forms  : — 

(a.)  Condition  of  the  ears  in  the  27  patients  who  were  entirely 
deaf : — 

In  1  each  ear  was  apparently  healthy. 

4  the  surface  of  each  membrana  tympani  was  dull. 

1  each  membrana  tympani  was  concave. 

2  "  "  "         fallen  in. 

3  "  "  "         perforated. 

13  "  "  "         absent,  and  there  was  catarrh 

of  the  tympanic  mucous  membrane. 
3  each  meatus  formed  a  cul-de-sac  about  half  an  inch  from  its 
orifice. 

[b.)  Condition  of  the  9  patients  by  whom  certain  sounds  are 
heard  : — 

27 


418  THE     DISEASES    OF    THE     EAR. 

In  tlic  single  individual  who  heard  a  clapping  of  the  hands,  each 

membrana  tympani  was  absent. 
Of  the  fee  who  heard  a  loud  voice  : — 
In  1  the  membrana  tympani  was  fallen  in. 

2          "  "  "         perforated,  and  there  was  a  poly- 

pus in  the  meatus. 

2  "  "  "         absent  in  each  ear. 
Of  the  two  who  pronounced  the  vowels  : — 

In  1  the  membrana  tympani  was  dull  and  opaque. 

1  in  the  right  ear  the  membrana  tympani  was  fallen  in  ;  in  the 

left  ear  it  was  absent. 
In  the  0)ic  child  who  pronounced  short  words  both  ears  were  appa- 
rently natural. 

Condition  of  the  ears  in  the  23  cases  of  deaf  ness  from  fever  : — 

(a.)  In  the  17  who  did  not  hear  any  sound : — 

3  were  apparently  healthy. 

In  2  each  meatus  was  distended  by  cerumen. 
3  each  membrana  tympani  was  opaque. 
1 
1 

2  " 
1 
1 
1  each  meatus  full  of  paper,  each  membrana  tympani  fallen  in 

and  red. 
1  right  ear,  the  membrana  tympani  concave  and  thick  ;  left  ear. 

membrana  tympani  perforated  and  fallen  in. 
1  right  ear  contained  a  polypus ;    in  left  ear  the  membrana 

tympani  was  absent. 

(h.)  In  the  6  who  heard  sounds. 
In  the  four  who  heard  a  shout : — 

1  each  membrana  tympani  was  dull  and  opaque. 
1         "  "  "         perforated;    the  mucous  mem- 

brane of  the  tympanum  being  thick. 
1  each  membrana  tympani  was  dull. 

1  right  ear,  the  membrana  tympani  was  perforated ;  left  ear, 
the  membrana  tympani  fallen  in  and  corrugated. 


dull. 

white  and  shrivelled. 

fallen  in. 

perforated. 

destroyed  by  ulceration 

ON    THE     DEAF    AND     DUMB.  419 

In  the  single  instance  in  whicli  a  loud  voice  was  heard,  each  mem- 
brana  tympani  was  opaque ;  and  in  the  case  Avhere  the  patient  tried 
to  articulate  "words  after  the  speaker,  each  ear  was  apparently 
normal. 


Condition  of  the  ear  in  the  four  cases  of  measles: — 

(a.)  Of  the  three  who  were  deaf: — 

In  1  each  ear  was  apparently  normal. 

1  each  membrana  tympani  white  and  thick. 

1  right  ear,  the  membrana  tympani  dull ;    left  ear,  membrana 
tympani  dull,  and  fallen  in. 

(5.)  In  the  patient  who  heard  a  clap  of  the  hands,  each  membrana 
tympani  was  thick  and  white. 

Condition  of  the  ear  in  the  35  cases  of  deafness  produced  hy  va- 
rious diseases,  as  teething,  convulsions,  hydrocephalus,  a  fall,  Jits,  a 
fright,  ^c. : 

In  seventeen  cases  each  ear  appeared  to  be  normal.  In  several  of 
the  others  the  membrana  tympani  was  dull  on  the  surface,  opaque, 
or  concave.  In  three  cases  it  had  fallen  in ;  but  in  only  two  was  it 
perforated :  thus  showing  a  marked  difference  between  the  effects  of 
these  diseases  and  those  of  scarlet  fever ;  where  it  will  be  remem- 
bered that,  in  20  out  of  36  cases,  each  membrana  tympani  was 
either  absent  or  perforated.  I  will  give,  first,  the  condition  of  the 
ears  in  the  patients  entirely  deaf,  and  then  the  condition  of  those 
having  various  degrees  of  hearing. 

(a.)  Condition  of  the  ears  in  the  26  patients  who  were  entirely 
deaf: — 

14  appeared  natural. 
In  2  each  membrana  tympani  was  dull. 

3  "  "  opaque. 

4  "  "  concave. 
1                  "                 "  fallen  in. 


420  THE     DISEASES    OF    THE    EAR. 

1  one  ear  appeared  natural ;  in  the  other  the  membrana  tympani 

was  fallen  in. 
1  in  one  ear  the  membrana  tympani  was  opaque  ;  in  the  other  it 

was  absent. 
In  the  case  where  the  clap  of  the  hands  was  lieard,  each  ear  ap- 
peared to  be  natural. 

(b.)  Of  the  three  who  heard  a  shout : — 

1  appeared  to  be  natural. 
In  1  each  membrana  tympani  was  opaque. 

1  the  membrana  tympani  of  one  ear  was  concave,  and  it  was  na- 

tural in  the  other. 

(<?.)  Of  the  four  who  heard  a  loud  voice  : — 

1  appeared  natural. 
In  1  each  membrana  tympani  was  opaque. 

2  the  membrana  tympani  of  each  ear  had  fallen  in. 

In  the  single  case  where  the  vowels  were  heard,  the  membrana 
tympani  of  one  ear  was  opaque,  and  it  was  perforated  in  the  other. 


III.    ox   THE    CONDITION   OF   THE    EAR   IN   THE   DEAF    AXD    DUMB,    AS 
REVEALED    BY   DISSECTION. 

It  is  highly  desirable  that  careful  dissections  should  be  made  of 
the  ears  of  deaf  and  dumb  patients  whose  cases  have  been  carefully 
noted  during  life,  in  order  that  tlie  condition  of  the  organ  may  be 
compared  with  the  amount  of  hearing  possessed  by  the  patient.  Pa- 
thological investigations  into  the  condition  of  the  ear  in  the  deaf  and 
dumb  have,  however,  been  too  seldom  conducted,  to  enable  us  to 
draw  any  conclusive  general  deductions  as  to  the  condition  of  the 
ear  in  deaf-mutes.  I  purpose  now  to  give  the  details  of  five  dissec- 
tions performed  by  myself,  and  to  follow  them  with  a  tabular  view 
of  the  morbid  appearances  found  in  all  the  other  dissections  of  simi- 
lar cases  that  have  been  met  with  by  me. 

Dissection  1. — A  woman,  xt.  40,  deaf,  and  consequently  dumb, 
from  birth.  For  the  last  ten  years  of  her  life  she  was  insane,  and 
was  confined  in  a  lunatic  asylum.     The  petrous  bones  were  sent  to 


ON    THE    DEAF    AND     DUMB.  421 

me,  immediately  after  tlie  death  of  the  patient,  by  tlie  late  Mr. 
Crosse,  of  NorAvich. 

Right  ear. — The  meatus  externus,  membrana  tympani,  and  the 
tympanic  cavity  were  in  a  healthy  state.  Labyrinth. — The  anterior 
limb  of  the  superior  semicircular  canal  commvmicatcd  "with  the  ves- 
tibule, but  was  rather  larger  than  natural,  and  its  shape  somewhat 
irregular.  Examined  as  it  passes  inwards,  it  was  observed  to  ter- 
minate in  a  cul-de-sac,  after  having  attained  only  half  its  usual 
length.  The  portion  of  bone  in  the  situation  usually  occupied  by 
the  inner  part  of  the  canal  was  of  an  ivoid  whiteness,  and  could  be 
distinctly  distinguished  from  the  surrounding  bone.  The  greater 
part  of  the  posterior  semicircular  canal  Avas  absent,  its  anterior  and 
posterior  extremities  presenting  tAVO  cul-de-sacs,  half  a  line  in  length. 
The  external  semicircular  canal,  the  vestibule,  and  cochlea,  were  in 
a  normal  state. 

Left  ear. — The  superior  semicircular  canal  is  in  the  same  incom- 
plete state  as  that  of  the  right  ear. 

Dissection  2. — J.  C,  set.  50,  died  from  fever.  He  was  born 
deaf,  and  had  been  educated  as  a  deaf-mute. 

Right  ear. — Meatus  externus  in  a  natural  state,  excepting  that 
one  part  of  the  osseous  parietes  Avas  quite  rough.  Membrana  tym- 
pani thicker  than  natural,  and  perforated :  a  small  red  polypus  was 
attached  to  its  dermoid  layer.  A  membranous  band  connected  the 
stapes,  incus,  and  tensor  tympani  muscle.  The  osseous  semicircular 
canals  Avere  large  ;  but  they  did  not  contain  any  membranous  tubes. 
The  cochlea  AA-as  in  a  normal  state,  as  Avere  also  the  tympanic  muscles 
and  nerves. 

Left  ear. — The  osseous  semicircular  canals  did  not  contain  any 
membranous  tubes.  One  of  the  osseous  canals  Avas  so  contracted  as 
to  admit  of  the  passage  through  it  of  a  fine  wire  only. 

Dissection  3. — R.  B.,  ?et.  16,  a  girl,  sharp  and  intelligent. 
Her  parents  stated  that  she  was  born  deaf;  but  the  child,  on  the 
contrary,  said  that  she  had  heard  sounds.  Her  teacher  thought 
the  child's  statement  to  be  more  likely  to  be  correct,  as  she  pro- 
nounced many  AA'ords  according  to  their  proper  sounds.  None  of 
her  relatives  AAxre  deaf-mutes.  Upon  making  a  careful  dissection  of 
each  car,  no  deviation  from  the  normal  condition  could  be  detected 
in  the  meatus  externus,  membrana  tympani,  or  tympanic  cavity. 
The  stapes  adhered  to  the  fenestra  ovalis  Avith  its  usual  degree  of 
firmness.     The  membranous  labyrinth  in  the  vestibule  was  healthy, 


422  THE    DISEASES    OF    THE    EAR. 

as  also  was  that  in  the  semicircuhir  canals,  Avith  this  exception,  that 
in  the  middle  of  the  superior  semicircular  canal  in  the  right  ear  ■svas 
a  quantity  of  otoconie  (ear  crystals),  Avhich  completely  obstructed 
the  tube. 

From  the  occurrence  of  an  accident  to  the  left  ear,  it  was  not 
possible  to  ascertain  its  condition. 

Dissection  4. — A  boy,  set.  15,  -who  had  been  wholly  deaf  from 
his  birth.  No  deviation  from  the  normal  state  in  either  ear  could 
be  detected  by  me. 

Dissection  5. — For  the  opportunity  of  making  this  dissection,  I 
am  indebted  to  Dr.  Ormerod,  of  Brighton.  The  ears  were  taken 
from  a  young  woman  deaf  and  dumb,  with  discharge  from  each  ear. 
She  died  with  tubercular  inflammation  of  the  brain. 

Right  ear. — The  membrana  tympani  was  absent ;  the  mucous 
membrane  of  the  tympanum  red,  and  of  extreme  thickness,  so  as  to 
fill  the  whole  of  the  tympanic  cavity  and  to  conceal  the  stapes  ;  the 
tympanum  was  distended  with  dark-colored  blood.  The  petrous 
bone  was  so  intensely  hard,  that  it  could  with  difficulty  be  cut  by 
the  bone  forceps.  The  cochlea,  to  the  naked  eye,  had  a  natural 
appearance,  and  submitted  to  microscopic  examination,  no  deviation 
from  the  normal  structure  could  be  detected,  excepting  in  that  por- 
tion of  the  lamina  spiralis  which  is  near  to  the  vestibule.  This, 
instead  of  being  composed  of  a  delicate  osseous  lamina  and  a  fine 
membrane,  the  two  making  a  delicate  septum  between  the  scala 
tympani  and  scala  vestibuli,  presented  a  mass  of  solid  bone  filling 
up  the  scala  tympani,  and  concealing  from  view  the  membrana 
fenestra)  rotundac  ;  the  inner  surface  of  which  it  wholly  covered. 
The  outer  surface  of  this  membrane  could,  however,  be  distinctly 
seen  from  the  tympanic  cavity,  and  it  appeared  natural. 

The  semicircular  canals  contained  more  otoconie  than  natural. 

Lrft  ear. — The  membrana  tympani  absent.  The  mucous  mem- 
brane of  the  tympanum  thick  and  red,  as  in  the  right  ear.  The 
semicircular  canals  containcMl  more  otoconie  than  natural,  and  espe- 
cially the  posterior  one,  which,  at  its  junction  with  the  posterior 
limb  of  the  superior  canal,  was  wholly  distended  with  crystals  for 
the  extent  of  half  a  line.  The  lamina  spiralis  of  the  cochlea  was 
of  a  deep  red  color,  and  blood  was  effused  in  both  scahe.  The  part 
of  the  lamina  spiralis  near  to  the  vestibule  was  in  the  same  state  as 
the  same  portion  in  the  right  ear. 

In  the  subjoined  table  the  condition  of  the  ears  in  deaf-mutes,  as 
revealed  by  various  reported  dissections,  is  shown. 


ON    THE    DEAF    AND    DUMB. 


423 


A  TABULAR  VIEW  OF  THE  CONDITION  OF  THE  EAR  IN  THIRTY-SIX 
DISSECTIONS  OF  DEAF-MUTES. 


Meatus 
ExterDUS. 

Membrana 
Tympani. 

Tympanum. 

Labyrinth. 

Nerve. 

Name  of 
Observer. 

Absent. 

.* 

As  soft  us 
mucus. 

Iliud. 

Absent. 

Fabricius. 

Absent. 

Do. 
Itard. 

Destroyed. 

Containing     vege- 
tations from  the 
mucous        mem- 
brane ;      ossicles 
absent. 

Do. 

Do. 

Do. 

Do. 

Partially 
destroyed. 

Containing  scrofu- 
lous matter. 

Mr.  Cock. 

Do. 

Do. 

... 

Do. 

Containing    calca- 
reous        concre- 
tions. 

Do. 
Itard. 

Full  of  gelatinous 
matter. 

Full  of  gelatinous 
matter. 

Do. 

Containing  a  yel- 
low fluid. 

Harder 

than 
natural. 

Rosenthal. 

Anchylosis  of 
stapes  to  fenestra 
ovalis. 

Valsalva. 

.  .  . 

All     the     ossicles 
wanting. 

Vestibule     full    of 
caseous  matter. 

Cochlea   consisting 
of  only  one  turn 
and  a  half. 

Vestibule,       coch- 
lea, and  semicir- 
cular  canals   ab- 
sent. 

Semicircular      ca- 
nals wanting. 

Reimarus. 
Dr.  Haighton. 

Mundini. 

Meckel. 
Murer. 

*  Where  no  entry  is  made,  it  is  to  be   assumed  that  the  part  of  the  organ  was  in  a 
healthy  state. 


424 


THE    DISEASES    Of    TU£    EAR. 


Meatus 
Externum.  I 


Membrana 
Tympani. 


Tympanum. 


Labyrinth. 


Name  of 

Obscrrer. 


Partially 
destroyed. 


Destroyed. 


All     the     ossicles 
wanting. 


Mucous 
membrane  thick. 


Two  of  the  semi- 
circular canals 
imperfect.  j 

Do.  I 


Atrophied. 
Indurated. 
Wanting. 


Fenestra  rotunda 
closed  by  bone  in 
each  ear. 

One  semicircular 
canal  incomplete 
in  one  ear  only ; 
the  other  ear 
healthy. 

Aquaeductus  vesti- 
buli  very  large. 


Semicircular      < 
nals  absent  in  one 
ear. 

Filled  with  caseous 
matter. 


A  portion  of  one  of 
the  membranous 
semicircular  ca- 
nals filled  with 
otoconie. 

The  superior  and 
posterior  semicir- 
cular canals  in- 
complete in  right 
ear ;  the  superior 
incomplete  in  the 
left  ear. 

Membranous  semi- 
circular canals 
absent. 


Lamina        sjiiralis  Otoconie  ob- 
I    near  the  vestibule     structing 

filling    the    scala    the  canals. 
I    tympani.  | 


Very  hard. 


naif  its 
usual  size. 

Atrophied. 

Compressed 
by  a  tumor. 


Mr.  Cock. 

Do. 

Sylvius. 

Ameman. 
Morgagni. 
Mr.  Cock. 

Dr.  Thurnam. 

Dalrymple. 

Rosenthal. 
Murer. 

Dr.  Haighton. 

Hoffman. 
Duverney. 

Author. 
Do. 


Do. 

Do. 
Do. 


ON    THE    DEAF    AND    DUMB.  425 


IV.    ON  THE  MODE  OF  EXAMINING  A  CHILD  SUPPOSED  TO  BE  DEAF 

AND  DUMB. 

From  the  absence  of  precise  experiments  from  which  accurate 
conclusions  could  be  dra-\vn,  great  difference  of  opinion  frequently 
exists,  even  among  medical  men,  as  to  whether  a  child  suspected  of 
being  deaf  and  dumb  really  is  so. 

It  frequently  happens,  therefore,  that  a  child  is  reported  not  to 
be  deaf,  because  it  always  starts  or  looks  up  Avhen  the  door  of  the 
room  is  loudly  knocked,  or  the  floor  over  the  room  is  tapped  with 
considerable  force,  or  the  fire-irons  in  the  room  are  permitted  to 
fall,  or  the  piano  is  played.  A  similar  opinion  is  often  formed 
because  a  child  can  utter  some  short  syllables,  as  "Mam,"  "Pa," 
&c.,  it  being  argued  that  no  child  could  learn  to  utter  these  sounds 
unless  it  had  heard  them.  It  is  also  asserted,  that  a  child  could 
not  have  been  born  deaf,  because  the  defect  was  not  discovered  until 
it  had  reached  the  age  of  a  year  and  a  half  or  two  years. 

In  reply  to  the  above  arguments  in  favor  of  a  child's  being  able 
to  hear,  it  must  be  borne  in  mind  that  loud  sounds  are  always 
accompanied  by  more  or  less  vibration  of  the  walls  and  floor  of  the 
apartment,  which  can  be  felt  by  a  person  whose  attention  may  thus 
be  attracted,  although  totally  deaf.  A  child  may  also  learn  to  utter 
short  words  by  simply  imitating  the  movements  of  the  lips  of  the 
parent,  or  nurse,  without  the  exercise  of  the  sense  of  hearing.  The 
plan  adopted  by  me  to  ascertain  Avhether  a  young  child  is  deaf,  con- 
sists, in  the  first  place,  of  allowing  it  to  sit  on  the  knee  of  the 
nurse  or  parent,  and  be  amused  by  something,  and  then  while  its 
eyes  are  fixed  upon  the  object,  to  speak  loudly,  or  shout,  taking 
especial  care  that  the  breath  does  not  reach  the  patient.  Again, 
let  the  child,  its  attention  distracted  as  before,  be  placed  with  its 
back  towards  the  surgeon,  who  should,  when  near  it,  clap  his  hands 
loudly,  ring  a  large  bell,  or  blow  a  powerful  Avhistle,  always  taking 
care  that  his  OAvn  shadoAV  is  not  seen,  and  that  the  child  is  screened 
from  the  movements  of  the  air,  while  the  nurse  is  warned  not  to 
start  or  suddenly  look  up ;  or  the  surgeon  may  come  into  a  room, 
the  door  of  which  has  been  some  time  open,  and  wliere  the  child  is 
seated  with  its  back  toAvards  him  surrounded  by  toys,  and  perform 
similar  experiments.  If  the  child  does  not  evince  any  symptom  of 
hearing,  by  suddenly  lifting  up  its  eyes,  turning  round,  or  starting, 


426  THE     DISEASES     OF    THE     EAR. 

it  must  be  concluded  that  it  is  wholly  deaf ;  but  if,  on  the  contrary, 
it  looks  up  each  time  the  surgeon  shouts,  or  turns  round  quickly  the 
instant  the  hands  are  clapped,  it  is  evident  that  some  power  of 
hearing  exists,  and  steps  should  be  taken  to  ascertain  the  extent  of 
such  power,  and  how  far  it  may  enable  the  child  to  be  orally  taught. 


V.    ON  THE  MEDICAL  TREATMENT  OF  THE  DEAF  AND  DUMB. 

It  is  of  great  importance  that  the  surgeon  should  be  able  to  decide 
what  treatment,  if  any,  should  be  pursued  when  deaf  and  dumb 
children  are  brought  to  him. 

The  first  rule  which  may  be  laid  down  is,  that  in  those  cases 
where  there  is  no  hearing  power  whatever,  and  in  which  it  is  sup- 
posed that  the  nervous  apparatus  is  either  incomplete  or  much  dis- 
organized, no  treatment  for  the  purpose  of  improving  the  hearing 
should  be  resorted  to.  The  friends  of  the  child  should  be  told  that 
there  is  no  hope  of  any  change,  and  that  it  will  have  to  be  educated 
as  a  deaf-mute. 

On  the  contrary,  should  there  be  a  certain  decided  amount  of 
hearing  power,  some  attempt,  it  is  obvious,  should  be  made  to  de- 
velop it.  Where  the  child  is  evidently  born  deaf,  general  medicinal 
treatment  is  not  required ;  and  the  only  remedy  is  the  use  of  means 
to  excite  the  nervous  system  of  the  ears  to  natural  action.  By  the 
persevering  use  of  the  long  elastic  tube,  the  hearing  power  has,  in 
some  cases,  been  decidedly  increased. 

In  cases  where  by  disease  subsequent  to  birth,  either  the  mem- 
brana  tympani,  or  the  mucous  membrane  lining  the  tympanum,  has 
been  thickened,  counter-irritation  over  the  mastoid  process  will  aid 
the  use  of  trumpets  ;  and  in  those  where  the  membrana  tympani  has 
been  partially  or  wholly  destroyed  by  ulceration,  and  where  there 
is  a  constant  discharge  of  mucus  from  the  surface  of  the  tympanic 
mucous  membrane,  it  is  desirable  for  the  ears  to  be  syringed,  and 
occasionally  with  a  weak  astringent,  so  as  to  prevent  the  membrane 
becoming  idcerated,  and  the  bone  which  it  covers,  carious.  The 
artificial  drum  may  also  be  resorted  to. 


ON    THE    DEAF    AND     DUMB.  427 


VI.    THE   AMOUNT    OF    HEARING    POSSESSED    BY   CHILDREN    EDUCATED 
AS    DEAF   AND    DUMB. 

The  examination  of  a  large  number  of  children  usually  considered 
to  be  wholly  deaf,  and  consequently  educated  as  deaf-mutes,  shows 
that  a  large  proportion  are  not  totally  deaf,  but  that,  on  the  contrary, 
certain  sounds  are  distinctly  heard.  Thus,  it  will  be  observed,  that 
of  the  411  children  examined  at  the  Deaf  and  Dumb  Asylum,  245, 
or  three-fifths,  were  quite  deaf,  not  hearing  any  sound  ;  while  166, 
or  two-fifths,  heard  certain  sounds.  The  166  cases  in  which  certain 
sounds  were  perceptible,  may  be  classified  as  follows : — 

14  heard  a  clapping  of  the  hands. 

51  heard  a  shout  close  to  the  ears. 

50  heard  a  loud  voice  close  to  the  ears. 

44  distinguished  vowels,  and  repeated  them. 

6  repeated  short  words. 

1  repeated  short  sentences. 

166 

Of  the  411  children  it  has  already  been  stated  that  313  were  cases 
of  congenital  deafness,  while  98  were  acquired  cases. 

Of  the  313  congenital  cases — 
172,  or  about  five-ninths,  were  deaf — i.  e.,  no  sounds  were  heard 

by  them. 
141  heard  certain  sounds. 


313  congenital  cases. 

The  141  cases  in  which  certain  sounds  were  heard  may  be  classi- 
fied as  follows  : — 

11  heard  a  clapping  of  the  hands  near  to  the  head. 

44  heard  a  shout. 

39  heard  a  loud  voice. 

41  heard  the  vowels,  and  repeated  them. 

5  heard  words,  and  repeated  them. 

1  heard  short  sentences,  and  repeated  them. 


428  THE    DISEASES    OF    THE    EAR. 

Of  the  98  acquired  cases — 
73,  or  about  three-fourths  were  deaf. 
25  heard  certain  sounds. 

The  25  acquired  cases  in  which  certain  sounds  ^Ycre  heard  may  be 
particularized  as  follows  : — 

Arising  from  scarlet  fever,  9  : — 

1  hears  a  clapping  of  the  hands. 
5  hears  a  loud  voice. 

2  pronounce  the  vowels. 

1  pronounces  short  words. 

Fever,  6 : — 

4  hear  a  loud  shout. 

1  hears  the  voice. 

1  hears  the  voice,  and  tries  to  imitate  it. 

Measles,  1 : — 

1  hears  a  loud  clapping  of  the  hands. 

Various  Diseases,  9  : — 
1  hears  a  loud  clapping  of  the  hands. 

3  hear  a  shout. 

4  hear  a  loud  voice. 
1  repeats  the  vowels. 


VII.  ON  THE  EDUCATION  OF  THE  DEAF  AND  DUMB. 

The  observations  to  be  offered  upon  the  system  usually  adopted 
for  the  education  of  the  deaf  and  dumb,  have  reference  to  two  points : 
first,  the  improvement  of  the  power  of  hearing ;  second,  the  use  of 
the  vocal  organs. 


1.    Of  the  improvement  of  the  j^oiver  of  Jicaring. 

It  would  be  very  interesting  to  know  how  far  the  facts  respecting 
the  hearing  power  of  so-called  deaf  and  dumb  children,  cited  in  a 


ON    THE    DEAF    AND     DUMB.  429 

previous  part  of  this  chapter,  are  corroborated  by  the  observations 
of  others.  Itard  hazarded  the  opinion  that  one-half  of  the  pupils 
at  the  Deaf  and  Dumb  Institution  at  Paris  were  -wholly  deaf,  and 
that  the  other  half  heard  some  sounds.  It  is  assumed  by  the  writer 
of  the  very  interesting  article  on  the  Deaf  and  Dumb,  in  the  "  Penny 
Cyclopjedia,"  that  the  same  proportion  of  the  totally  deaf  to  those 
who  hear  a  little,  will  be  met  with  in  our  English  institutions.  If 
there  exist  throughout  the  deaf  and  dumb  in  England  relatively,  as 
many  cases  of  a  large  amount  of  hearing  as  in  the  London  Institu- 
tion, steps  taken  to  improve  the  hearing  power  might  be  productive 
of  the  most  valuable  results ;  especially  as  my  own  limited  experi- 
ence warrants  the  assertion  that  this  power  is  capable  of  considerable 
development,  as  may  be  seen  by  the  cases  appended.  Though  one 
of  these  does  not  belong  to  the  category  of  the  deaf  and  dumb,  yet 
the  long  duration  of  nearly  total  deafness  in  one  ear,  followed  by  so 
great  a  restoration  of  its  dormant  power,  renders  the  case  of  great 
interest  in  the  present  inquiry.  The  treatment  calculated  to  im- 
prove the  hearing,  consists  in  the  use  of  trumpets,  whereby  the 
nervous  apparatus  may  be  gradually  excited,  as  to  become  sensitive 
to  ordinary  sonorous  undulations  and  external  stimulants.  While 
quite  agreeing  with  Mr.  "Wilde,  that  we  cannot  hope  to  cure  cases 
of  deaf-mutism,  I  still  think,  when  there  already  exists  the  power 
to  hear  the  vowels  so  distinctly  as  to  distinguish  and  repeat  them, 
that  from  the  exercise  of  the  ear  considerable  improvement  may 
reasonably  be  anticipated ;  suflBcient,  in  fact,  to  aid  in  carrying  out 
the  end  above  all  things  to  be  desired,  viz.,  the  exercise  of  the  organs 
of  speech. 

The  influence  of  the  use  of  the  vocal  organs  upon  the  general 
health  has,  it  seems  to  me,  scarcely  been  sufficiently  considered  in 
the  education  of  the  deaf  and  dumb.  Sir  H.  Holland,  with  his 
usual  acuteness,  has  placed  the  subject  in  its  just  light.  He  says  : 
"  Might  not  more  be  done  in  practice  towards  the  prevention  of 
pulmonary  diseases,  as  well  as  for  the  improvement  of  the  general 
health,  by  expressly  exercising  the  organs  of  respiration  ;  that  is, 
by  practising,  according  to  some  method,  those  actions  of  the  body, 
through  which  the  chest  is  alternately  in  part  filled  or  emptied  of 
air  ?  Though  suggestions  to  this  efiect  occur  in  some  of  our  best 
works  on  Consumption,  as  well  as  in  the  writings  of  certain  conti- 
nental physicians,  they  have  hitherto  had  less  than  their  due  in- 
fluence, and  the  principle  as  such  is  little  recognized  or  brought 


430  TUE     DISEASES    OF    THE    EAR. 

into  general  application.  In  truth,  common  usage  takes,  for  the 
most  part,  a  directly  opposite  course,  and,  under  the  notion  or 
pretext  of  quiet,  seeks  to  repress  all  direct  exercise  of  this  impor- 
tant function  in  those  who  are  presumed  to  have  a  tendency  to 
pulmonary  disorders." — 3Iedieal  Notes,  c.  xx,  b.  422. 

To  this,  I  may  be  allowed  to  add,  in  reference  to  the  deaf  and 
dumb,  that  in  those  cases  where  the  organs  of  speech  are  not  used, 
and  where,  consequently,  the  lungs,  and  the  muscles  of  the  chest, 
and  heart,  are  not  duly  exercised  by  the  act  of  articulation,  the 
general  health  always  suffers. 

But  the  great  advantage  of  calling  forth  the  auditory  power  of 
so-called  deaf-mutes  is,  that  they  may  be  enabled  to  hear  their  own 
voices,  and  to  modulate  them  ;  for  the  extreme  harshness  and 
monotony  of  the  sounds  produced  by  deaf-mutes,  arise  from  the  im- 
possibility of  regulating  the  tones  of  a  voice  which  they  cannot 
distinguish. 

CASES. 

Miss  L.  L.,  get.  23,  consulted  me  in  the  early  part  of  the  year 
1857.  Her  history  was,  that  since  childhood  she  had  heard  only 
certain  loud  sounds,  and  was  quite  deaf  to  all  conversation.  Iler 
means  of  comprehending  what  was  spoken  Avere  derived  from 
watching  the  movements  of  the  lips,  and  the  sounds  she  uttered 
appeared  to  be  the  result  of  her  attempts  at  imitating  the  move- 
ments she  saw.  Upon  examination,  having  found  that  the  voice 
was  heard  Avhen  spoken  into  the  ears,  I  recommended  counter- 
irritation  and  the  use  of  a  long  elastic  tube.  At  first  she  could 
hear  only  for  from  three  to  five  minutes  at  a  time.  In  a  fortnight 
there  was  decided  improvement  in  the  hearing  power,  and  she  began 
to  experience  a  painful  sensation  in  the  ears  when  too  loudly  spoken 
to.  To  use  the  words  of  her  sister  (who  devoted  herself  to  the 
poor  patient  in  a  way  that  only  a  sister  or  parent  could),  "  During 
the  third  week  the  improvement  was  wonderful.  This  was  not  so 
perceptible  with  the  tul)e  as  in  her  hearing  generally.  Everything 
was  so  much  louder  to  her,  but  not  more  distinct.  The  noise  in 
the  street  now  quite  annoyed  her  :  she  called  it  dreadful,  although, 
when  we  arrived  in  town,  she  did  not  notice  it.'"  She  left  me  at 
the  end  of  a  month's  treatment,  and  I  directed  her  to  be  spoken  to 
daily,  but  only  in  words  of  one  syllable,  which  she  was  to  repeat  to 


ON    THE    DEAF    AND     DUMB.  431 

herself.  Then  very  simple  sentences  were  tried  ;  which  she  heard 
and  understood  when  spoken  to  through  the  tube  in  the  ordinary 
way  of  conversing,  and  replied  by  speaking  through  the  tube  her- 
self, so  that  she  was  able  to  hear  her  own  voice  and  modulate  it. 
Her  sister  writes :  "  In  October,  1857,  she  spent  three  weeks  at 

,  and  there  she  was  seen  by  people  Avho  saw  her  just  before 

she  came  to  consult  you:  they  said  they  should  not  have  believed 
it  possible  for  her  to  have  improved  so  much  in  hearing  and  articu- 
lation; her  mind,  too,  had  come  out  so.  During  the  three  weeks 
she  was  from  home,  she  had  a  complete  holiday  (e.  e.,  the  tube  was 
not  used),  and  when  she  came  back,  the  hearing  had  not  retrograded 
generally,  but  she  did  not  hear  so  well  through  the  tube.  Since 
her  return  from  a  visit,  she  has  gone  steadily  on  Avith  the  use  of  the 
tube.  Latterly," — this  was  written  on  February  2d, — "  for  some 
weeks,  I  have  talked  through  the  tube  daily  an  hour  divided  into 
three  or  four  intervals.  Two  or  three  times,  when  much  amused, 
she  bore  its  use,  without  fatigue,  half  an  hour  at  a  time,  and  she 
said  she  could  have  borne  it  longer.  Even  when  she  has  had  a 
difficulty  in  comprehending  what  was  said,  I  have  never  allowed  her 
once  to  see  my  lips  while  talking  through  the  tube.  We  spelt  the 
words  which  she  could  not  make  out,  and  she  never  once  failed  to 
find  them  out  by  tlie  aid  of  the  ear  alone.  One  afternoon  she  could 
not  understand  a  single  word  of  sentences  she  had  distinctly  heard 
in  the  morning.  By  degrees,  however,  she  made  out  a  word  here 
and  there,  and  in  a  few  minutes  heard  everything  I  said.  She  had 
been  absorbed  in  writing  a  letter  till  a  minute  or  so  before  the  use 
of  the  tube.  Several  times  now,  I  observed  that  she  heard  far 
more  easily  at  the  end  of  our  talk  than  at  the  beginning.  To  her 
best  ear  I  am  obliged  to  talk  in  a  high  treble,  not  loud.  The  left 
ear  requires  a  deeper,  stronger  voice.  Great  distinctness  and  slow- 
ness are  necessary — a  monotonous  tone  suits  her  best.  The  final 
consonants  must  be  strongly  uttered.  She  says  she  now  hears  them, 
but  she  never  did  so  before.  She  notices  the  difierence  of  touch  in 
persons  playing  on  the  piano,  and  can  often  understand  much  that 
is  said  without  seeing  the  mouth.  A  few  days  since  she  exclaimed, 
'  You  are  talking  French.'  Lately  she  has  gained  many  new 
phrases,  trying  to  apply  those  she  hears  in  conversation,  very  often 
making  wonderful  mistakes.  Not  long  ago  she  said,  '  That  tree  is 
a  great  assortment  for  the  birds,'  meaning  '  resort  for.'  At  another 
time  she  said,  '  I  hope  you  will  not  think  me  liberty,'  meaning,  '  I 


432  THE    DISEASES    OF    THE    EAR. 

hope  YOU  will  not  think  I  take  a  liberty.'  She  began  to  read  half 
an  hour  a  day ;  it  was  hard  work,  although  the  book  was  written 
for  a  child.  As  hearing  improyed,  articulation  and  intelligence 
improyed,  and  lately  I  haye  often  wondered  at  the  change.  We 
increased  the  reading  to  an  hour,  my  sister  constantly  saying,  '  I 
feel  as  if  something  were  coming  to  my  mind,'  and  expressing  sur- 
prise that  she  could  understand  what  she'neyer  could  comprehend 
before.  She  noAV  quite  distinguished  between  my  mode  of  pro- 
nouncing and  her  own,  and  we  never  had  the  tube  while  reading  to 
her,  as  I  knew  its  use  would  have  distracted  her  thoughts  from  her 
book.  Occasionally,  when  the  word  was  a  yery  difficult  one,  she 
made  it  out,  and  then  had  the  tube  used  to  convince  her  of  her 
correctness.  Numbers  of  people  have  remarked  my  sister's  im- 
provement. A  lady  saw  her  the  first  time  in  the  beginning  of 
August  last,  and  she  saw  her  no  more  till  November,  when  she  said 
to  me  in  astonishment,  '  I  could  not  understand  a  word  your  sister 
said  in  August ;  now  I  can  understand  everything  she  says.'  "When 
I  began  your  plans,  I  had  to  ask  my  sister,  as  a  favor  to  myself,  to 
allow  me  to  talk  to  her  sometimes ;  she  was  annoyed,  and  then  did 
not  hear  so  well.  Now,  things  are  very  different.  She  very  often 
proposes  the  use  of  the  tube,  and  says  she  wishes  you  could  know 
what  we  had  done  for  her." 

Another  case,  very  similar  to  the  above,  also  occurred  to  me  lately. 

A  young  lady,  ret.  between  twenty  and  thirty,  like  the  case  above 
cited,  had  never  heard  sounds  so  as  to  be  able  to  speak  or  read  with 
any  degree  of  distinctness.  I  subjected  her  to  a  treatment  similar 
to  that  pursued  in  the  above  case,  and  the  result  was  also  satisfac- 
tory. In  about  four  months  I  received  the  following  report  in  a 
letter  from  her  sister:  "I  do  think  she  (the  patient)  is  improving; 
a  good  many  of  her  friends  also  think  so."  In  another  letter  the 
same  sister  writes  :  "■  I  really  do  think  the  improvement  gradu- 
ally continues,  although  slowly,  which  perhaps  is  the  best  and 
surest."  The  patient  herself  writes  :  "  I  cannot  tell  how  much  I 
have  improved  in  hearing,  reading,  and  speaking ;  but  I  now  read 
much  better,  and  I  knoAv  the  numbers  very  well  by  the  tube.  I 
hear  everything  continually.  The  G.'s,  during  my  visit  there,  and 
Aunt  F.,  say  my  improvement  is  much  in  speaking  ;  they  under- 
stand me  very  well,  and  I  am  very  glad  of  it." 


ON    THE    DEAF    AND     DUMB.  433 


Tlie  right  ear  useless  for  xixty  years  ;  at  the  age  of  seventy  so  greatly 
improved  as  to  hear  conversation  all  over  the  room,  by  means  of  a 
trumpet. 

I  was  called  into  the  country  in  great  haste  in  tlic  spring  of  1856, 
to  see  a  nohleman,  «?t.  70,  who  was  suffering  from  an  attack  of  in- 
tense inflammation  of  the  mucous  membrane  lining  the  left  tympanic 
cavity.  At  the  time  of  my  seeing  the  patient,  the  inflammation  had 
extended  internally  as  far  as  the  labyrinth,  and  the  power  of  hear- 
ing was  destroyed.  The  only  means  of  communication  with  my 
patient  was  by  writing.  Having  but  slight  hope  of  doing  anything 
towards  the  improvement  of  the  hearing  power  of  the  left  ear,  I 
turned  my  attention  to  the  right,  the  drum  of  which  had,  I  found, 
been  inflamed  and  damaged  in  early  life.  I  proposed,  amid  opposi- 
tion at  the  supposed  utter  uselessness  of  the  experiment,  to  try  the 
effect  of  a  loud  voice  spoken  into  the  right  ear.  The  result  was 
decided,  the  sound  of  the  voice  was  distinctly  heard,  and  some 
words  were  understood.  Feeling  that  the  nervous  system  of  this 
ear  was  lying  torpid,  from  the  circumstance  that  ordinary  sonorous 
undulations  had  not  been  able  to  reach  it  through  the  diseased  con- 
dition of  the  membrana  tympani  and  mucous  membrane  of  the  tym- 
panum, and  also  from  the  w^eak  state  of  the  nerve  itself,  I  determined 
to  try  a  plan  of  treatment  having  a  twofold  object, — the  excitement 
of  the  nervous  apparatus  of  the  ear  by  the  healthy  stimulus  of 
sonorous  vibrations,  through  the  use  of  ear-trumpets,  and  an  im- 
provement of  the  condition  of  the  drum,  as  also  of  the  mucous 
membrane  of  the  tympanum,  by  remedial  applications.  The  former 
of  these  objects  was  attempted  at  once  with  a  most  satisfactory  re- 
sult, for  the  hearing  power  gradually  increased.  In  short,  by  the 
means  in  question,  the  latter  of  the  two  being  principally  gentle 
counter-irritation,  the  patient's  power  of  hearing  in  this  ear,  which 
had  been  so  defective  during  sixty  years  that  its  faculty  was  con- 
sidered "lost,"  became,  in  the  course  of  eighteen  months,  so  im- 
proved, that  for  a  long  time  previous  to  his  death,  he  could  hear  a 
voice  speaking  near  to  the  ear,  and  with  the  aid  of  a  trumpet  on  his 
table  could  carry  on  a  conversation  with  persons  sitting  in  different 
parts  of  an  ordinary  sized  room.     In  this  case  I  am  confident  that 

28 


434 


THE     DISEASES     OF     THE     EAR. 


no  good  would  have  resulted  from  the  treatment,  if  the  nervous  ap- 
paratus of  the  ear  had  not  been  stimulated  at  the  same  time  by  the 
influence  of  sounds  ;  and  my  experience  tells  me  that  liundreds  of 
persons  are  living  with  one  ear  supposed  to  be  perfectly  deaf,  and 
in  reality  useless,  but  which  might  be  made  very  serviceable,  were 
the  sonorous  undulations  conveyed  to  it  by  artificial  means. 


CHAPTER  XIX. 

EAR-TRUMPETS  AND  THEIR  USE. 

In  some  cases  of  climinislied  power  of  hearing,  there  can  be  no 
doubt  that  ear-trumpets  afford  great  assistance,  and  arc  a  source  of 
much  comfort  to  the  sufferers.  On  the  other  hand,  if  imprudently 
used,  they  are  apt  to  increase  the  deafness  and  to  cause  additional 
distress.  They  are  decidedly  injurious,  for  instance,  in  the  early 
stages  of  deafness  arising  from  debility  of  the  nervous  apparatus, 
and  the  noises  are  likely  to  be  increased  by  their  use  ;  Avhile  in  the 
old  standing  cases  of  the  same  disease  they  often  prove  most  service- 
able :  they  are  also  equally  advantageous  in  cases  of  partial  anch}'- 
losis  of  the  stapes  to  the  fenestra  ovalis. 

Ear-trumpets  may  be  considered  under  three  different  classes, 
according  to  their  use,  in  as  many  degrees  of  deafness. 

The  first  class  consists  of  instruments  to  be  worn  on  or  in  the 
ears,  without  the  aid  of  the  hand ;  and  by  means  of  which  more 
voices  than  one,  or  even  general  conversation,  can  be  heard. 

The  most  useful  of  this  class  of  instruments  are  the  small  cornets 
made  by  Mr.  Rein,  which  are  connected  by  a  spring  passing  over 
the  head,  that  serves  also  to  hold  them  in  the  ears.  The  cornets 
can  be  concealed  by  the  hair  or  worn  under  the  bonnet.  A  variety 
of  this  class  is  a  small  cornet,  which  can  equally  be  concealed  by  the 
liair,  and  which  fits  into  the  ear,  where  it  is  retained  by  a  convolu- 
tion which  passes  around  the  ear  and  dispenses  with  the  spring. 

The  second  class  consists  of  instruments  held  in  the  hand,  by 
means  of  Avhich  one  voice,  and  sometimes  more,  spoken  near  the 
extremity,  can  be  heard. 

To  this  class  belong  all  the  varieties  of  trumpet  of  different 
lengths  and  shapes,  Vhether  made  of  tin,  gutta-percha,  &c.,  and 
consisting  of  a  narrow  portion  inserted  into  the  eai-,  which  graduallv 


436  THE    DISEASES     OF    THE    EAR. 

expands  into  a  Avide  mouth.  These  trumpets  must  be  held  in  the 
hand,  and  the  expanded  portion  can  be  directed  to  any  person  or 
persons  whose  voices  are  desired  to  be  heard. 

The  tliird  class  embraces  a  variety  of  elastic  tubes,  one  end  being 
placed  in  or  on  the  patient's  ear,  and  the  other  held  in  the  hand  of 
the  speaker,  whose  mouth  being  applied  near  or  in  its  free  extremity, 
his  single  voice  is  heard. 


APPENDIX. 


LIST  OF  PUBLISHED   PAPERS   ON  THE  STRUCTURE,  FUNCTIONS, 
AND  DISEASES  OF  THE  EAR. 

On  the  structure  of  the  membrana  tympani  in  the  human  ear.  With 
numerous  engravings.  Pidlosoplucal  Transactions,  1851.  Parti. 

On  the  functions  of  the  membrana  tympani.  Proceedings  of  the 
Royal  Societg,  1852. 

On  the  muscles  -which  open  the  Eustachian  tube.  Proceedings  of  the 
Royal  Society,  1853. 

On  the  mode  in  which  sonorous  undulations  are  conducted  from  the 
membrana  tympani  to  the  labyrinth,  in  the  human  ear.  Pro- 
ceedings of  the  Royal  Society,  1859. 

Pathological  researches  into  the  diseases  of  the  ear.  Medico-Chirur- 

gical  Transactions,  vol.  xxiv,  1841. 
Pathological  researches  into  the  diseases  of  the  ear.     Second  series. 

3Iedico-Chiriirgical  Transactions,  vol.  xxvi,  1843. 
Pathological  researches  into  the  diseases  of  the  ear.     Third  series. 

Medico- Chii'urgical  Transactions,  vol.  xxxii,  1849. 
Pathological  researches  into  the  diseases  of  the  ear.     Fourth  series. 

Medico-Chirurgical  Transactions,  vol.  xxxiv,  1851. 
Pathological  researches  into  the  diseases  of  the  ear.     Fifth  series. 

Medico-Chirurgical  Transactions,  vol.  xxxviii,  1855. 
Pathological  researches  into  the  diseases  of  the  car.     Sixth  series. 

Medico-Chirurgical  Transactions,  vol.  xxxviii,  1855. 
On  the  diagnosis  of  the  condition  of  the  Eustachian  tube,  by  means 

of  the  otoscope,  without  the  use  of  the  catheter.    Proceedings  of 

the  Royal  3Iedical  and  Chirurgical  Society.     Medical  Timcx 

and  Gazette,  April  9,  1853. 


438  THE     DISEASES    OF    THE     EAR. 

The  results  of  some  inquiries  respecting  the  deaf  and  dumb.  Pro- 
ceedings of  the  lioyal  3Iedical  and  Cldrurgical  Society.  3IedicaI 
Times  and  Gazette,  1856. 

On  anchylosis  of  the  stapes  to  the  fenestra  ovalis  (stapedio-vestihular 
articulation)  associated  Avith  rheumatism  and  gout ;  illustrated 
by  more  than  one  hundred  dissections.  Proceedings  of  the  Royal 
Medical  and  Chirurgical  Society,  1858. 

A  case  of  deaf-dumbness,  of  more  than  twenty  years'  duration,  in 
Avhich  the  hearing  and  the  articulation  Avere  greatly  benefited. 
Proceedings  of  the  Hoy al  Medical  and  Chirurgical  Society,  1858. 

On  the  nature  and  treatment  of  those  diseases  of  the  ear  which 
have  hitherto  been  designated  otorrhoea  and  otitis.  Trans- 
actions of  the  Provincial  3Iedical  and  Surgical  Association, 
vol.  xviii. 

On  osseous  tumors  growing  from  the  walls  of  the  meatus  externus 
of  the  ear,  and  on  the  enlargement  of  the  walls  themselves, 
with  cases.  Wood-cuts.  Proceedings  of  the  Provincial  Medical 
and  Surgical  Association.  The  Journal  of  the  Association. 
1849. 

On  the  use  of  an  artificial  membrana  tympani,  in  cases  of  perfora- 
tion or  destruction  of  the  organ.  Proceedings  of  the  Provincial 
Medical  and  Surgical  Association.      The  Journal,  1852. 

Disease  of  the  tympanic  cavity,  causing  caries  of  the  bone  and 
paralysis  of  the  portio  dura  nerve. 

Osseous  tumors  developed  from  the  parietes  of  the  external  auditory 
meatus. 

Disease  of  the  external  auditory  meatus,  with  suppuration  of  the 
brain. 

Series  of  preparations,  illustrative  of  the  diseases  of  the  membrana 
tympani. 

Bony  stricture  of  the  Eustachian  tube.  Transactions  of  the  Patholo- 
gical Society  of  London,  vol.  i,  1849-1850. 

A  series  of  cases,  illustrating  diseases  in  the  cerebral  cavity,  origi- 
nating in  affections  of  the  auditory  meatus. 
Neuroma  of  the  auditory  nerve. 
Molluscous  tumors  developed  in  the  external  auditory  meatus. 


APPENDIX.  439 

The  effects  of  molluscous  tumors  on  the  petrous  bone,  Avlicn  do- 
veloped  in  the  external  auditory  meatus. 

Prcj^arations  illustrative  of  hypertrophy  in  the  epidermoid  and  der- 
moid lamimxj  of  the  membrana  tympani. 

Caries  of  the  petrous  bone  and  abscess  of  the  cerebellum.  Trans- 
actions of  the  Pathological  Society,  vol.  ii,  1850-1851. 

Congenital  malformation  of  the  external  ear  and  meatus  on  each  side. 

Calcareous  matter  in  the  cavity  of  the  vestibule. 

Examination  of  the  ears  of  a  deaf  and  dumb  child,  in  ^\•hich  a 
portion  of  one  of  the  membranous  semicircular  canals  was  dis- 
tended with  otoconie. 

Disease  of  the  base  of  the  brain,  extending  from  the  tympanum 
through  the  labyrinth. 

Necrosis  of  the  squamous  portion  of  the  temporal  bone,  originating 
in  catarrhal  inflammation  of  the  external  meatus. 

Cholesterine  in  the  mastoid  cells.  Transactions  of  the  Pathological 
Society,  vol.  iii,  1851-1852. 

Case  of  ulceration  of  the  fibrous  lamini^  of  the  membrana  tympani. 
Case  of  complete  bony  anchylosis  of  the   stapes  to  the  fenestra 

oval  is. 
A  case  of  perforate  membrana  tympani  treated  by  the  substitution 

of  an  artificial  membrane. 
On  the  mode  of  dissecting  the  ear  for  pathological  investigation. 
Neuroma  of  the  auditory  nerve.      Transactions  of  the  Pathological 

Society,  vol.  iv,  1852-1853. 

Caries  of  the  temporal  bone,  and  disease  of  the  brain  produced  by 
retention  of  the  discharge  in  the  tympanum,  after  scarlet  fever, 
by  the  thickened  membrana  tympani. 

Anchylosis  of  the  stapes. 

Disease  of  the  ear  affecting  the  lateral  sinus  and  cerebellum. 
Transactions  of  the  Pathological  Society,  vol.  v,  1853-1854. 

Encephaloid  disease  of  the  tympanic  cavity,  extending  to  the  brain. 
Acute  inflammation  of  the  mastoid  cells  extending  to  the  brain. 
On  the  causes  of  accumulations  of  cerumen  in  the  meatus  audito- 

rius  externus,  and  their  effects  on  different  parts  of  the  ear. 

Transactions  of  the  Pathological  Society,  vol.  vi,  1855-1856. 


440  THE    DISEASES      OF    THE    EAR. 

Dissection  of  a  case  of  malfovmation  in  the  ears  of  a  child.  Edin- 
burgh Montldy  Journal  of  Medical  Science^  1847. 

On  the  pathology  and  treatment  of  the  deafness  attendant  upon  old 
age.  3IonfJdf/  Journal  and  Hetrosjyect  of  the  Medical  Sciences. 
Nos.  98  and  99,  1849. 

Case  of  stricture  of  the  Eustachian  tube,  -with  an  account  of  the 
appearances  presented  on  dissection.  Monthly  Journal  of 
Medical  Science,  1850. 

On  the  tuhular  ear  speculum.      The  Lancet,  Oct.  1,  1850. 

On  tlie  removal  of  foreign  bodies  from  the  ear.  Provincial  Medi- 
cal and  Surgical  Journal,  1850. 

On  the  nature  and  treatment  of  polypi  of  the  ear.  3fedical  Times 
and  Gazette,  1852. 

On  the  excision  of  the  tonsils  and  uvula  in  the  treatment  of  deaf- 
ness.    Medical  Times  and  Gazette,  1853. 

On  the  removal  of  polypi  from  the  ear  by  the  lever-ring  forceps  and 
the  dressing-ring  forceps.     3Iedical  Times  and  Gazette. 

On  the  functions  of  the  muscles  of  the  tympanum  in  the  human  ear. 
British  and  Foreign  3Iedico-Chirurgieal  Revieiv,  1853. 

On  the  use  of  an  artificial  membrana  tympani  in  cases  of  deafness 
dependent  upon  perforation  or  destruction  of  the  natural  organ. 
Octavo.     1853. 

Do.,  do.,  Sixth  Edition,  1858. 

A  course  of  clinical  lectures  on  the  pathology  and  treatment  of  the 
affections  of  the  ear  causing  disease  in  the  brain  or  its  mem- 
branes, delivered  at  St.  Mary's  Hospital.  With  engravings. 
3Iedical  Times  and  Gazette,  1855. 

A  course  of  lectures  on  the  nature  and  treatment  of  the  diseases  of 
the  ear,  delivered  at  St.  Mary's  Hospital  Medical  School. 
Medical  Times  and  Gazette,  1856. 

A  descriptive  catalogue  of  preparations  illustrative  of  the  diseases 
of  the  ear  in  the  museum  of  the  author.     8vo.  1857. 


THE     END. 


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*^*  We  have  just  issued  a  new  edition  of  our  Illustrated  Catalogue  of  Medical 
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Churchill's  Midwifery, "  9 

Dickson's  Elements  of  Medicine, "10 

Druiit's  Surgery, «'  10 

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Hamilton  on  Fractures  and  Dislocations, "  18 

Hodge  on  Diseases  of  Women "  19 

Meigs  on  Diseases  of  Women, "  ^1 

Parrish's  Practical  Pharmacy, "  25 

Stille's  Therapeutics  and  Materia  Medica, "  27 

Simpson  on  Diseases  of  Women, "  27 

Todd's  Clinical  Lectures, "  28 

Toynbee  on  the  Ear, "  29 

Watson's  Practice  of  Physic, "  30 

Walshe  on  the  Lungs, "  30 

Wilson's  Human  Anatomy, "  31 

Winslow  on  Brain  and  Mind, "  32 

West  on  Diseases  of  Children "  32 

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Address  BLANCHARD  &  LEA,  Philadiuhia. 


AND    SCIENTIFIC    PUBLICATIONS. 


ASHTON   (T.  J.), 

Surgeon  to  the  Blenlieim  Dispensary,  &c. 

ON   THE   DISEASES,  INJURIES,  AND   MALFORMATIONS   OF   THE 

RECTUM  AND  ANUS;  with  remarks  on  Habitual  Constipation.  From  the  third  and  enlarged 
London  edition.  With  handsome  illustrations.  In  one  very  beautifully  printed  octavo  volume, 
of  about  300  pages.  (Now  Ready.)  §2  00. 
Introduction.  Chapter  I.  Irritation  and  Itching  of  the  Anus.  II.  Inflammation  and  Excoria- 
tion of  the  Anus.  III.  E.Kcrescences  of  the  Anal  Region.  IV.  Contraciioti  of  the  Amis.  V. 
Fissure  of  the  Anus  and  lower  part  of  the  Rectum.  Vi.  Neuralgia  of  the  Anus  and  exiremitv 
of  the  Rectum.  VII.  Inllammalion  of  the  Rectum.  Vlll.  Ulceration  of  the  Rectum.  IX.  He- 
morrhoidal Aflectioiis.  X.  Enlargement  of  Hemorrhoidal  Veins.  XI.  Prolapsus  of  the  Rectum. 
XII.  Abscess  near  the  Rectum.  XIII.  Fistula  in  Ano.  XIV.  Pol  vpi  of  the  Rectum.  XV.  Stric- 
ture of  the  Rectum.  XVI.  Malignant  Diseases  of  the  Rectum.  XVII.  Injuries  of  the  Rectum 
XVIII.  Foreign  Bodies  in  the  Rectum.  XIX.  Malformations  of  the  Rectum.  XX.  Habitual 
Constipation. 

reach  of  American  practitioners.  We  are  satisfied 
after  a  carel'ul  examination  of  the  volume,  ami  a 
comparison  of  its  contents  with  those  of  its  leading 


The  most  complete  one  we  possess  on  the  subject. 
Medico-Chirurgieal  Review. 


Its  merits  as  a  practical  instructor,  well  arranged, 


preilecessors  and  contemporaries,  that  llie  best  way 


abundantly  t'urnished  with  illustrative  cases,  and  for  the  reader  to  avail  himself  of  the  excellent  nd- 
clearly  and  comprehensively,  albeit  too  diffusely,  vicegiven  in  theconcludingparagraph  above,  would 
written,  are  incontestable.  They  have  been  sufR-  !  be  to  provide  himself  with  a  c  ipy  of  tiie  book  from 
ciently  endorsed  by  the  verdict  of  his  countrymen  which  it  has  been  taken,  and  diligently  to  con  its 
in  the  rapid  exhaustion  of  the  first  edition,  and  tliev  ',  instructive  pages.  They  may  secure  to  him  many 
would  certainly  meet  with  a  similar  reward  in  the  1  a  triumph  and  I'ervent  blessing.— jIot.  Journal  Med. 
United  Slates  were  the  volume  placed  within  the  1  Sciences,  April,  155S. 


ALLEN    (J.    M.),    M.  D., 

Professor  of  Anatomy  in  the  Pennsylvania  Medical  College,  &c. 

THE  PRACTICAL  ANATOMIST;  or.  The  Student's  Guide  iu  the  Dissecting- 

ROOM.     With  266  illustrations.    In  one  handsome  royall2mo.  volume,  of  over  600  pages,  lea- 
ther.    $2  25. 


However  valuable  may  be  the  "  Dissector's 
Guides"  which  we,  of  late,  have  had  occasion  to 
notice,  we  feel  confident  that  the  work  of  Dr.  Allen 
is  superior  to  any  of  them.  We  believe  with  the 
author,  that  none  is  so  fully  illustrated  as  this,  and 
the  arrangement  of  the  work  is  such  as  to  facilitate 
the  labors  of  the  student  in  acquiring  a  thorough 
practical  knowledge  of  Anatomy.    We  most  cordi- 


ally recommend  it  to  their  attention. — Western  Lan- 
ce . 

We  believe  it  to  be  one  of  the  most  useful  works 
upon  the  subject  ever  written.  It  is  handsomely 
Illustrated,  well  printed,  and  will  be  found  of  con- 
venient size  for  use  in  the  dissecting-room. — Med. 
Examiner. 


ANATOMICAL   ATLAS. 
By  Professors  H.  H.  Smith  and  W.  E.  Horner,  of  the  University  of  Pennsyl- 
vania.   1  vol.  8vo.,  extra  cloth,  with  nearly  650  illustrations.    |3^  See  S.mith,  p.  27. 


ABEL  (F.   A.),    F.  C.  S.    AND    C.    L.    BLOXAM. 
HANDBOOK  OF  CHEMISTRY,  Theoretical,  Practical,  and  Technical;  with  a 

Recommendatory  Preface  by  Dr.  Hofmann.  In  one  large  octavo  voliune,  extra  cloth,  of  662 
pages,  with  illustrations.    $3  25. 

ASHWELL    (SAMUEL),   M.D., 

Obstetric  Physician  and  Lecturer  to  Guy's  Hospital,  London. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  PECULIAR  TO  WOMEN. 

Illustrated  by  Cases  derived  from  Hospital  and  Private  Practice.  Third  American,  from  the  Third 
and  revised  London  edition.    In  one  octavo  volume,  extra  cloth,  of  528  pages.     $3  00. 
The  most  useful  practical  work  on  the  subject  in  j      The  most  able,  and  certainly  the  most  standard 
the  English   language.  — jB 05ton   Med.  and  ^'urg.    and  practical,  work  on  female  diseases  that  we  have 
Journal.  \  yet  seen. — Medico-CMrurgical  Revieto. 

ARNOTT   (NEILL),  M.  D. 
ELEMENTS    OF    PHYSICS;    or  Natural  Philosophy,  General  and  Medical. 

Written  for  universal  use,  in  plain  or  non-technical  language.  A  new  edition,  by  Isaac  Hays, 
M.  D.  Complete  in  one  octavo  volume,  leather,  of  484  pages,  with  about  two  hundred  illustra- 
tions.    $2  50.  

BIRD  (GOLDING),  A.  M.,  M.  D.,  «tc. 
URINARY     DEPOSITS:     THEIR     DIAGNOSIS,    PATHOLOGY,    AND 

THERAPEUTICAL  INDICATIONS.  Edited  by  Edmlnd  Lloyd  BiRKETr,  M.  D.  A  new 
American,  from  the  fifth  and  enlarged  London  edition.  With  eighty  illustrations  on  wood.  In  one 
handsome  octavo  volume,  of  a'joui  400  pages,  extra  cloth.     $2  00.     (Ju^t  Issued.) 

The  death  of  Dr.  Bird  has  rendered  it  necessary  to  entrust  the  revision  of  the  present  edition  to 
other  hands,  and  in  his  performance  of  the  duty  thus  devolving  on  him.  Dr.  Birketl  has  sedulously 
endeavored  to  carry  out  the  author's  plan  by  introducing  such  new  matter  and  modifications  of 
the  text  as  the  progress  of  science  has  called  for.  Notwithstanding  the  utmost  care  to  keep  the 
work  within  a  reasonable  compass,  these  additions  have  resulted  in  a  considerable  enlargement. 
It  is,  therefore,  hoped  that  it  will  be  found  fully  up  to  the  present  condition  of  the  subject,  and  that 
the  reputation  of  the  volume  as  a  clear,  complete,  and  compendious  manual,  will  be  fully  maintained. 


BUDD  (GEORGE),  M.  D.,  F.  R.  S., 

Professor  of  Medicine  in  King's  College,  London. 

ON  DISEASES   OF  THE  LIVER.      Third  American,  from   the  third  and 

enlarged  London  edition.    In  one  very  handsome  octavo  volume,  extra  cloth,  with  four  beauti- 
fully colored  plates,  and  numerous  wood-cuts.     pp.  500.     $3  00. 

Has  fairly  established  for  itself  a  place  among  the  is  not  perceptibly  changed,  the  history  of  liver  dis- 
classioal  medical  literature  of  England. — British  eases  is  made  more  complete,  and  is  kept  upon  a  level 
an>i  Foreign  Medico-Chir.  Review,  July,  1857.  '  with  the  progress  of  modern  science.     It  is  Ihe  best 

Dr.  Budil's  Trealise  on  Diseases  of  the  Liver  is  ^"^'^  ""  Diseases  of  the  Liver  in  any  language.— 
now  a  standard  work  in  Medical  literature,  and  dur-  London  Med.  Times  and  Gazette,  June  27,  ie57. 
ing  the  mtcrvals  which  have  elapsed  between  the  This  work,  now  the  standard  book  of  reference  on 
successive  editions,  the  author  has  incorporated  into  i  the  diceases  of  which  it  treats,  has  been  carefully 
the  text  the  most  striking  novelties  which  have  cha-  I  revised,  and  many  new  illustrations  of  the  views  of 
racterized  the  recent  progress  of  hepatic  physiology  [  the  learned  author  iidded  in  the  present  edition. — 
and  pathology;  so  thataltliough  the  size  of  the  book     Dublin  Quarlerlt/  Journal,  Aug.  1&57. 

BY  THE  SAME  AUTHOR. 

ON  THE   ORGANIC  DISEASES   AND  FUNCTIONAL  DISORDERS  OF 

THE  STOMACH.    In  one  neat  octavo  volume,  extra  cloth.    $1  50. 


BUCKNILL  (J.  C),   M.  D., 

Medical  Superintendent  of  the  Devon  County  Lunatic  Asylum;  and 
DANIEL   H.   TUKE,    M.  D., 

Visiting  Medical  Officer  to  the  York  Retreat. 

A  MANUAL  OP   PSYCHOLOGICAL   MEDICINE;   containing  the  History, 

Nosology,  De>cription,  Statistics,  Diagnosis,  Pathology,  and  Treatment  of  INSANITY.     With 

a  Plate.     In  ore  handsome  octavo  volume,  of  536  pages.     $3  00. 

The  increase  of  mental  disease  in  its  various  forms,  and  the  dillieult  questions  to  which  it  is 
constantly  giving  rise,  render  the  subject  one  of  daily  enhanced  interest,  requiring  on  the  part  of 
the  physician  a  constantly  greater  familiarity  with  this,  the  most  perplexing  branch  of  his  profes- 
sion. At  the  same  time  there  has  been  for  some  years  no  work  accessible  in  this  country,  present- 
ing the  results  of  recent  investigations  in  the  Diagnosis  and  Prognosis  of  In.^anity,  and  the  greatly 
improved  methods  of  treatment  which  have  done  so  much  in  alleviating  the  condition  or  restoring 
the  health  of  the  insane.  To  fill  this  vacancy  the  publishers  present  this  volume,  assured  that 
the  distinguished  reputation  and  experience  of  the  authors  will  entitle  it  at  once  to  the  confidence 
of  both  student  and  practitioner.  Its  scope  may  be  gathered  from  the  declaration  of  the  authors 
that  "their  aim  has  l)een  to  supply  a  te.xt  book  which  may  serve  as  a  guide  in  the  acquisition  ol 
such  knowledge,  sufficiently  elementary  to  be  adapted  to  the  wants  of  the  student,  and  sufficiently 
modern  in  its  views  and  explicit  in  its  teaching  to  suffice  for  the  demands  of  the  practitioner." 


BENNETT   (J.    HUGHES),    M.D.,    F.  R.  S.  E., 

Professor  of  Clinical  Medicine  in  the  University  of  Edinburgh,  &c. 

THE  PATHOLOGY  AND  TREATMENT  OF  PULMONARY  TUBERCU- 

LOSIS,  and  on  the  Local  Medication  of  Pharyngeal  and  Laryngeal  Diseases  frequently  mistaken 
for  or  associated  with,  Phthisis.     One  vol.  8vo., extra  cloth,  with  wood-cuts.    pp.  130.     $1  25. 


BENNETT   (HENRY),  M.  D. 
A  PRACTICAL   TREATISE    ON  INFLAMMATION  OF  THE  UTERUS, 

ITS  CERVIX  AND  APPENDAGES,  and  on  its  connection  with  Uterine  Disease.  To  which 
is  added,  a  Review  of  the  present  stale  of  Uterine  Pathology.  Fifth  American,  from  the  third 
English  edition.  In  one  octavo  volume,  of  about  500  pages,  extra  cloth.  S'2  00.  {Now  Ready.) 
The  ill  health  of  the  author  having  prevented  the  promised  revision  of  this  work,  the  present 

edition  is  a  reprint  of  the  last,  without  alteration.     As  the  volume  has  been  for  some  tune  out  of 

fjrint,  gentlemen  desiring  copies  can  now  procure  them. 


BOWMAN  (JOHN    E.),  M.D. 
PRACTICAL  HANDBOOK   OF    MKDICAL   CHEMISTRY.     Second  Ame- 
rican, from  the  third  and  revised  English  Edition.    In  one  neat  volume,  royal  12mo.,  extra  cloth, 
with  numerous  illustrations,    pp.  288.     $1  2b. 

BY  THE  SAME  AUTHOR. 

INTRODUCTION    TO    PRACTICAL    CHEMISTRY,    INCLUDING    ANA- 

LYSIS.    Second  American,  from  the  second  and  revised  London  edition.     Withnumerousillus- 
trations.    In  one  neat  vol.,  royal  12ino.,  extra  cloth,    pp.350.    $125. 

BKALR  ON  THE  LAWS  OF  HRALTH  IN  RE-  i  BUCKLER  ON  THE  KTIOLOGV,  PATHOLOGY, 
1-ATION  TO  MIND  AND  BODY.     A  Series  of  I      AND    TREATMENT   OF    FIBRO-BRONCHl- 
Letters  from  an  old  Practitioner  to  a  Patient.     In  I      TISAND    RIIEU.MATIC    PNEU.MONIA.      In 
one  volume,  royal  I'2mo.,  extra  cloth,     pp.  296.        one  8vo.  volume,  extra  cloth.     pp.l5U.    St  25. 
&"  cents.  I  BLOOD    AND    URLNE  (MANUALS  ON).     BY 


BUSHNAN'S  PHYSIOLOGY  OF  ANIMAL  AND 
VEGETABLE  LIFE;  a  Popular  Treatise,  on  the 
Functions  and  Phenomena  of  Organic  Life.  In 
one  handsome  royal  12mo.  volume,  extra  cloth, 
with  over  100  illustrations,    pp.234.    80  cents. 


JOHN  ^VILLIAM  GRIFFITH,  G.  OWEN 
REESE,  AND  ALFRED  MARKWICK.  One 
thick  volume,  royal  12mo.,  extra  cloth,  with 
plates,  pp.  460.  SI  25. 
BRODIE'S  CLINICAL  LECTURES  ON  SUR- 
GERY.   1  vol.  8vo.  cloth.    350  pp.    8125. 


AND    SCIENTIFIC    PUBLICATIONS. 


BARCLAY  (A.  W.),  M.  D., 

Assistant  Physician  to  St.  George's  Hospital,  &.C. 

A  MANUAL  OF  MEDICAL  DIAGNOSIS ;   being  an  Analysis  of  the  Signs 
and  Symptoms  of  Disease.    Inoneneatoctavovolume,  extra  cloth,  of  424  pages.   $2  00.    {Lately 

issued.) 

Of  works  exclusively  devoted  to  this  important  |  The  task  of  composing  such  a  work  is  neither  an 
branch,  our  profession  Ims  at  command,  compara-  '  easy  nor  a  light  one  ;  but  Dr.  Barclay  has  performed 
lively,  but  few,  and,  therefore,  in  the  publication  of  ,  it  in  a  manner  which  meets  our  most  unqualified 
the  present  work,  Messrs.  Blanchard  <k  Lea  have  j  approbation.  He  is  no  mere  theorist;  he  knows  his 
conl'erred  a  great  favor  upon  us.  Dr.  Barclay^from  I  work  thoroughly,  and  in  attempting  to  perform  it, 
having  occupied,  for  a  long  period,  the  position  of!  has  not  exceeded  his  powers. — British  Med.  Journal, 
Medical  Registrar  at  St.  George's  Hospital, 


pos- 
sessed advantages  for  correct  observation  and  reli- 
able conclusions,  as  to  the  significance  of  symptoms, 
which  have  fallen  to  the  lot  of  but  few,  either  in 
his  own  or  any  other  country.  He  has  carefully 
systematized  the  results  of  his  observation  of  over 
twelve  thousand  patients,  and  by  his  diligence  and 
judicious  classification,  the  profession  has  been 
presented  with  the  most  convenient  and  reliable 
work  on  the  subject  of  Diagnosis  that  it  has  been 
our  good  fortune  ever  to  examine;  we  can,  there- 
fore, say  of  Dr.  Barclay's  work,  that,  from  his  sys- 


Dec.  5,  1857. 

We  venture  to  predict  that  the  work  will  be  de- 
servedly popular,  and  soon  become,  like  Watson's 
Practice,  an  indispensable  necessity  to  the  practi- 
tioner.— N.  A.  Med.  Journal,  April,  1S58. 

An  inestimable  work  of  reference  for  the  young 
practitiimer  and  student. — Nashville  Med.  Journal, 
May,  1858. 

We  hope  the  volume  will  have  an  extensive  cir- 
culation, not  among  students  of  medicine  only,  but 
practitioners  also.     They  will  never  regret  a  faith- 


tematic  manner  of  arrangement,  his  work  is  one  of  |  l"ul  study  of  its  pages. — Cincinnati  Lancet,  Mar.  '58. 


the  best  works  "  for  reference"  in  the  daily  emer- 
gencies of  the  practitioner,  with  which  we  are  ac- 
quainted ;  but,  at  the  same  time,  we  would  recom- 
niend  our  readers,  especially  the  younger  ones,  to 
read  thoroughlyand  study  diligently  theichole  work, 
and  the  ''emergencies"  will  not  occur  so  often. — 
Southern  Med.  and  Surg.  Journ.,  March,  1853. 

To  give  this  information,  to  supply  this  admitted 
deficiency,  is  the  object  of  Dr.  Barclay's  Manual. 


An  important  acquisition  to  medical  literature. 
It  IS  a  %vork  of  high  merit,  both  from  the  vast  im- 
portance of  the  subject  upon  which  it  treats,  and 
also  from  the  real  ability  displayed  in  its  elabora- 
tion. In  conclusion,  let  us  bespeak  for  this  volume 
that  attention  of  every  student  of  our  art  which  it 
so  richly  deserves— that  place  in  every  medical 
library  which  it  can  so  well  adorn. — Peninsular 
Medical  Journal,  Sept.  1858. 


BARLOW   (GEORGE  H.),    M.  D. 

Physician  to  Guy's  Hospital,  London,  &c. 

A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.     With  Additions  by  D. 

F.  CoNDiE,  M.D.,  author  of  "A  Practical  Treatise  on  Diseases  of  Children,"  &c.    In  one  hand- 
some octavo  volume,  leather,  of  over  600  pages.     $2  75. 

We  recommend  Dr.  Barlow'sManual  in  the  warm- 1  will  be  found  hardly  less  useful  to  the  experienced 
est  manner  as  a  most  valuable  vade-mecum.  We  :  physician.  The  American  editor  has  added  to  the 
have  had  frequent  occasion  to  consult  it,  and  have  |  work  three  chapters — on  Cholera  Infantum,  Yellow 
found  it  clear,  concise,  practical,  and  sound.  It  is  }  Fever,  and  Cerebro-spinal  Meningitis.  These  addi- 
eminently  a  practical  work,  containing  all  that  is  tions,  the  two  first  of  whicli  are  indispensable  to  a 
essential,  and  avoiding  useless  theoretical  discus-  I  work  on  practice  destined  for  the  profession  in  this 
sion.  The  work  supplies  what  has  been  for  some  country,  are  executed  with  great  judgment  and  fi- 
time  wanting;  a  manual  of  practice  based  upon  mo-  delity,  by  Dr.  Condie,  who  has  also  succeeded  hap- 
dern  discoveries  in  pathology  and  rational  views  of  pily  in  imitating  the  conciseness  and  clearness  of 
treatment  of  disease.  It  is  especially  intended  for  j  style  which  are  such  agreeable  characteristics  of 
the  use  of  students  and  junior  practitioners,  but  it  |  the  original  book. — Boston  Med.  and  Surg.  Journal. 


BARTLETT  (ELISHA),  M.  D. 
THE   HISTORY,  DIAGNOSIS,  AND  TREATMENT  OF  THE  FEVERS 

OF  THE  UNITED  STATES.    A  new  and  revised  edition.     By  Alonzo  Clark,  M.  D.,  Prof. 

of  Pathology  and  Practical  Medicine  in  the  N.  Y.  College  of  Physicians  and  Surgeons,  ifee.    In 

one  octavo  volume,  of  six  hundred  pages,  extra  cloth.    Price  $.3  00. 

It  is  the  best  work  on  fevers  which  has  emanated  i  logy.  His  annotations  add  much  to  the  interest  of 
from  the  American  press,  and  the  present  editor  has  the  work,  and  have  brought  it  well  up  to  the  condi- 
carefully  availed  himself  of  all  information  exist-  tion  of  the  science  as  it  exists  at  the  present  day 
ing  upon  the  subject  in  the  Old  and  New  World,  so  I  in  regard  to  this  class  of  diseases. — Southern  Med. 
that  the  doctrinesadvanced  arebrought  down  to  the  I  and  Surg.  Journal,  Mar.  1857. 

'«'esl  date  in  the  progress  of  this  department  of  |  ^-^^^  ^^^.^  ^f  great  practical  value  and  interest, 
Medical  Science.-Lo«do»  Med.  Times  and  Gazette,  containing  much  that  is  new  relative  to  the  several 
May  2,  lb57.  diseases  of  which  it  treats,  and,  with  the  additions 

Thisexcellent  monograph  on  febrile  disease,  has  of  the  editor, is  fully  up  to  the  times.  Thedistinct- 
gtood  deservedly  high  since  its  first  publication.  It  !  ivefeaturesof  the  different  forms  of  fever  are  plainly 
will  be  seen  that  it  has  now  reached  its  fourth  edi-  j  and  forcibly  portrayed,  and  the  lines  of  demarcation 
tion  under  the  supervision  of  Prof.  A.  Clark,  a  gen-  !  carefully  and  accurately  drawn,  and  to  the  Ameri- 
tleman  who,  from  the  nature  of  his  studies  and  pur-  i  can  practitioner  is  a  more  valuable  and  safe  guide 
suits,  is  well  calculated  to  appreciate  and  discuss  :  than  any  work  on  fever  extant. — Ohio  Med.  and 
the  many  intricate  and  difficult  questions  in  patho-  |  Surg,  Journal,  May,  1857. 


BROWN    (ISAAC    BAKER), 

Surgeon- Accoucheur  to  St.  Mary's  Hospital,  tec. 

ON  SOME  DISEASES  OF  WOMEN  ADMITTING  OF  SURGICAL  TREAT- 
MENT.   With  handsome  illustrations.    One  vol.  8vo.,  extra  cloth,  pp.  27i5.    $1  60. 

Mr.  Brown  has  earned  for  himself  a  high  reputa- ;  and  merit  the  careful  attention  of  every  aurgeoa- 
tion  in  the  operative  treatment  of  sundry  diseases  ^  accoucheur. — Association  Journal. 
and  injuries  to  which  females  are  peculiarly  subject,  i 
We  can  truly  say  of  his  work  that  it  is  an  important  I 


We  have  no  hesitation'in  recommending  this  book 


addition  to  obstetrical  literature.  The  operative  '"^'f  <="'■'='"'  attention  of  all  surgeons  who  mak^ 
suggestions  and  contrivances  which  Mr.  Brown  de-  ,  female  cornp.aints  a  partof  their  study  and  prHCti<«. 
scribes,  exhibit  much  practical  sagacity  and  gki\\\— Dublin  (quarterly  Journal. 


BLANUHAK.D   &   LiKA'S    Mt-UiUAL. 


CARPENTER  (WILLIAM    B.),  M.  D.,  F.  R.  S.,  &.C., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  applications  to 

Psychology,  Pathology,  Therapeutics-,  Hygiene,  and  Forensic  Medicine.  A  new  American,  from 
the  last  and  revised  London  edition.  With  nearly  three  hundred  illustrations.  Edited,  with  addi- 
tions, I)V  Francis  Gurney  Smith,  M.  D.,  Professor  of  the  Institutes  of  Medicine  in  the  Pennsyl- 
vania Medical  College,  &c.  In  one  very  large  and  beautiful  octavo  volume,  of  about  nine  hundred 
large  pages,  handsomely  printed  and  strongly  bound  in  leather,  with  raised  bands.     $4  25. 

In  the  preparation  of  this  new  edition,  the  author  has  spared  no  labor  to  render  it,  as  heretofore, 
a  complete  and  lucid  exposition  ol' the  most  advanced  condition  of  its  important  subject.  The 
amount  of  the  additions  required  to  eflect  this  object  thoroughly,  joined  to  the  former  large  size  of 
the  volume,  presenting  objections  arising  frpm  the  unwieldy  bulk  of  the  work,  he  has  omitted  all 
those  portions  not  bearing  directly  upon  HUiMAN  Physiology,  designing  to  incorporate  them  in 
his  forthcoming  Treatise  on  General  Physiology.  As  a  full  and  accurate  text-book  on  the  Phy- 
siology of  Man,  the  work  in  its  present  condition  therefore  presents  even  greater  claims  upon 
the  student  and  physician  than  those  which  have  heretofore  won  for  it  the  very  wide  and  distin- 
guished favor  which  it  has  so  long  enjoyed.  The  additions  of  Prof.  Smith  will  be  found  to  supply 
whatever  may  have  been  wanting  to  the  American  student,  while  the  introduction  of  many  new 
illustrations,  and  the  most  careful  mechanical  execution,  render  the  volume  one  of  the  most  at- 
tractive as  yet  issued. 

For  upwards  of  thirteen  years  Dr.  Carpenter's  i  To  eulogize  this  great  work  would  be  snperfluoue. 
work  has  been  considered  by  the  profession  gene-  We  should  observe,  however,  that  in  this  edition 
rally,  both  in  this  country  and  England,  as  the  most  the  author  has  remodelled  a  large  portion  of  the 
valuable  compendium  on  the  EUl>jeet  of  physiology  former,  and  the  editor  has  added  much  matter  of  in- 
in  our  language.  This  distinction  it  owes  to  the  high  terest,  especially  in  the  form  of  illustrations.  We 
attainments  and  unwearied  industry  of  its  accom-  may  confidently  recommend  it  as  the  most  complete 
plished  author.  Thepresent  edition  (which, like  the  work  on  Human  Physiology  in  our  language. — 
last  American  one,  was  prepared  by  the  author  him-  i  Southern  Med.  and  Surg.  Journal. 
self),  is  the  result  of  such  extensive  revision,  that  it  Thg  n,„st  complete  work  on  the  science  in  oar 
may  almost  be  considered  a  new  work.  We  need  language.— 4ot.  Med.  Journal. 
hardly  say,  in  concluding  this  briel  notice,  that  while  ,      ^.  ,  ,  .         ■  , 

the  work  is  indispensable  to  every  student  of  medi-        The  most  complete  work  now  extant  in  our  lan- 
■        ■■■  ■  •      guage. — N.  O.  Med.  Register. 


«ine  in  this  country,  it  will  amply  repay  the  practi- 
tioner for  its  perusal  by  the  interest  and  value  of  its 
contents. — Boston  Med.  and  Surg.  Journal. 


The  best  text-book  in  the  language  on  this  ex- 
tensive subject. — London  Med.  Times. 

A  complete  cyclopaedia  of  this  branch  of  science. 
— iV.  Y.  Med.  Times. 


This  is  a  standard  work — the  text-book  used  by  all  ! 
medical  students  who  read  the  Knglish  language. 
It  has  passed  through  several  editions  in  order  to  The  profession  of  this  country,  and  perhaps  also 
keep  pace  with  the  rapidly  growing  science  of  Phy-  of  E  urope,  have  anxiously  and  for  some  time  a  waited 
siology.  Nothing  need  be  said  in  its  praise,  for  its  the  announcement  of  this  new  edition  of  Carpenter's 
merits  are  universally  known;  we  have  nothing  to  Human  Physiology.  His  former  editions  have  for 
say  of  its  defects,  for  they  only  appear  where  the  many  years  been  almost  the  only  text-book  on  Phy- 
BCience  of  which  it  treats  is  incomplete. — Western,  siology  in  all  our  medical  schools,  and  itscircula- 
Lancet.  j  tion  among  the  professiim  has  been  unsurpassed  by 

Themostcompleteexpositionof  physiology  which  '  any  work  in  any  department  of  medical  science, 
any  language  can  at  present  eivo.— Brit,  and  For.        ^'  »»  quite  unnecessary  for  us  to  speak   of  this 
Med.-clirurg.  Review.  I  work  as  its   merits  would  justily.     The  mere  an- 

nouncement of  its  appearance  will  afford  the  highest 

The  greatest,  the  most  reliable,  and  the  best  book  pleasure  to  every  student  of  Physiology,  while  its 
on  the  subject  which  we  know  of  in  the  English  perusal  will  be  of  infinite  service  in  advancing 
language. — Stethoscopt.  |  physiological  science. — Ohio  Med.  and  Surg.  Joum. 


BY  THE   SAMK   AUTHOR. 

PRINCIPLES  OF  COMPARATIVE  PHYSIOLOGY.    New  American,  from 

the  Fourth  and  Revised  London  edition.     In  one  large  and  liandsome  octavo  volume,  with  over 
three  hundred  beautiful  illustrations,     pp.  752.     Extra  cloth,  $4  80 ;  leather,  raised  bands,  S5  25. 

The  delay  which  has  existed  in  the  appearance  of  this  work  has  been  caused  by  the  very  thorough 
revision  and  remodelling  which  it  has  undergone  at  the  hands  of  the  author,  and  the  laree  number 
of  new  illustrations  which  liave  been  prepared  for  it.  It  will,  therefore,  be  found  almost  a  new 
work,  and  fully  up  to  the  day  in  every  department  of  the  subject,  rendering  it  a  reliable  text-book 
for  all  students  engaged  in  this  branch  of  science.  Every  effort  has  been  made  to  render  its  typo- 
graphical finish  and  mechanical  execution  worthy  of  its  exalted  reputation,  and  creditable  to  the 
mechanical  arts  of  this  country. 


This  book  should  not  only  be  read  but  thoroughly 
studied  by  every  member  of  the  profession.  N«me 
are  too  wise  or  old,  to  be  benefited  thereby.  But 
especially  to  the  younger  class  would  we  cordially 
Commend  it  as  best  fitted  of  any  work  in  the  English 
language  to  qualify  them  for  the  reception  and  coin- 
pretiension  of  those  truths  which  are  daily  being  de- 
veloped in  physiology. — Medical  Counsellor. 

Without  pretending  to  it,  it  is  an  encyclopfdia  of 
the  subject,  accurate  and  complete  in  all  respects — 
a  truthl'ul  retlecticm  of  the  advanced  state  at  which 
the  science  has  now  arrived. — Dublin  Quarterly 
Journal  o/  Medical  Science. 

A  truly  magnificent  work — in  itself  a  perfect  phy- 
siological study. — Ranking'!  Abstract. 

This  work  stands  without  its  fellow.  It  is  one 
few  men  in  Europe  could  have  undertaken;  it  is  one 


1  no  man,  we  believe,  could  have  brought  to  so  suc- 
cessful an  issue  as  Dr.  Carpenter.  It  required  for 
its  production  a  physiologist  at  once  deeply  read  in 
the  labors  of  others,  capable  of  taking  a  general, 
critical,  and  unprejudiced  view  of  those  labors,  and 
of  combining  the  varied,  heterogeneous  m^lerials  at 

I  his  disposal,  so  as  to  form  an  harmonious  whole. 
We  feel  that  this  abstract  can  give  the  reader  a  very 
imperfect  idea  of  the  fulness  of  this  work,  and  no 
idea  of  its  unity,  of  the  admirable  manner  in  which 

,  material  has  ueeu  brought,  from  the  most  various 
sources,  to  ccmduce  to  its  completeness,  of  the  lucid- 
ity of  the  reasoning  it  contains,  or  of  the  clearness 
of^language  in  which  the  whole  is  clothed.  Not  the 
profession  only,  but  the  scientific  world  at  large, 
must  feel  deeply  indebted  to  Dr.  Carpenter  for  this 
great  work.  It  must,  indeed,  add  largely  even  to 
his  high  reputation. — Medical  Tirrus. 


AND    SCIENTIFIC    PUBLICATIONS 


CARPENTER  (WILLIAM  B.),   M.  D.,  F.  R.  S., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

THE  MICROSCOPE  AND  ITS  REVELATIONS.      With  an  Appendix  con- 

taming  the  Applications  of  the  Microscope  to  Clinical  Medicine,  iSrc.  By  F.  G.  Smith,  M.  D. 
Illustrated  by  lour  hundred  and  thirty-four  beautiful  engravings  on  wood.  In  one  large  and  very 
handsome  octavo  volume,  of  724  pages,  extra  cloth,  $4  00  ;  leather,  $4  50. 

Dr.  Carpenter's  position  as  a  microscopist  and  physiologist,  and  his  great  experience  as  a  teacher, 
eminently  qualify  him  to  produce  w^hat  has  long  been  wanted — a  good  text-book  on  the  practical 
use  of  the  microscope.  In  the  present  volume  his  object  has  been,  as  stated  in  his  Preface,  "  to 
combine,  within  a  moderate  compass,  that  information  with  regard  to  the  use  of  his  'tools,'  which 
is  most  essential  to  the  working  microsco|>ist,  wilh  such  an  account  of  the  objects  best  fitted  for 
his  study,  as  might  quality  him  to  comprehend  what  he  observes,  and  might  thus  prepare  him  to 
benefit  science,  whilst  expanding  and  refreshing  his  own  mind  "  That  he  has  succeeded  in  accom- 
plishing this,  no  one  acquainted  with  his  previous  labors  can  doubt. 

The  great  importance  of  the  microscope  as  a  means  of  diagnosis,  and  the  number  of  microsco- 
pists  who  are  also  physicians,  have  induced  the  American  publishers,  with  the  author's  approval,  to 
add  an  Appendix,  carefully  prepared  by  Professor  Smith,  on  the  applications  of  the  instrument  to 
clinical  medicine,  together  with  an  account  of  American  Micro>eopes,  their  modifications  and 
accessories.  This  portion  of  the  work  is  illustrated  with  nearly  one  hundred  wood-cuts,  and,  it  is 
hoped,  will  adapt  the  volume  more  particularly  to  the  use  of  the  American  student. 

Every  care  has  been  taken  in  the  mechanical  execution  of  the  work,  which  is  confidently  pre- 
sented as  in  no  respect  inferior  to  the  choicest  productions  of  the  London  press. 

The  mode  in  which  the  author  has  executed  his  intentions  may  be  gathered  from  the  following 
condensed  s-ynopsis  of  the 

CONTENTS. 

[ntroduction — History  of  the  Microscope.  Chap.  I.  Optical  Principles  of  the  Microscope. 
Chap.  II.  Construction  of  the  Microscope.  Chap.  III.  Accessory  Apparatus.  Chap.  IV. 
Management  of  the  Microscope  Chap.  V.  Preparation,  Mounting,  and  Collection  of  Objects. 
Chap.  VI.  Microscopic  Forms  of  Vegetable  Life — Protophyles.  Chap.  VII.  Higher  Cryptoga- 
mia.  Chap.  VIII.  Phanerogamic  Plants.  Chap.  IX.  Microscopic  Forms  of  Animal  Life — Pro- 
tozoa— Animalcules.  Chap.  X.  Foraminifera,  Polycystina,  and  Sponges.  Chap.  XI.  Zoophytes. 
Chap.  XII.  Echinodermata.  Chap.  XIII.  Polyzoa  and  Compound  Tunicata.  Chap.  XFV. 
Molluscous  Animals  Generally.  Chap.  XV.  Annulosa.  Chap.  XVI.  Crustacea.  Chap.  XVII. 
Insects  and  Arachnida.  Chap.  XVIII.  Vertebrafed  Animals.  Chap.  XIX.  Applications  of  the 
Microscope  to  Geology.  Chap.  XX.  Inorganic  or  Mineral  Kingdom — Polarization.  Appendix. 
Microscope  as  a  means  of  Diagnosis — Injections — Microscopes  of  American  Manufacture. 


Those  who  are  acquainted  with  Dr.  Carpenter's 
previous  writings  on  Animal  and  Vegetable  Physio- 
logy, will  fully  understand  how  vast  a  store  of  know- 
ledge he  is  able  to  bring  to  bear  upon  so  comprehen- 
sive a  subject  as  the  revelations  of  the  microscope  ; 
and  even  those  ■who  have  no  previous  acquaintance 
with  the  eonstruetion  or   uses  of  this  instrument 


medical  work,  the  additions  by  Prof.  Smith  give  it 
a  positive  claim  upon  the  profession,  for  which  we 
doubt  not  he  will  receive  their  sincere  thanks.  In- 
deed, we  know  not  where  the  student  of  medicine 
will  find  such  a  complete  and  satisfactory  collection 
of  microscopic  facts  bearing  upon  physiology  and 
practical  medicine  as  is  cimtained  in  Prof.  Smith's 


will  find  abundance  of  information  conveyed  in  clear  {  appendix;  and  this  of  itself,  it  seems  to  us,  is  fully 
and   simple  language. — Med.    Times  and   GazeUe.  [  wortJi  the  cost  of  the  volume. — Louisville  Medical 
Although  originally  not  intended  as  a  strictly!  Review ,  N  ov .  1856 . 

BY   THE  SAME   AUTHOR. 

ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHYSIO- 

LOGICAL  ANATOMy.    Second  American,  from  a  new  and  revised  London  edition.     With 

one  hundred  and  ninety  illustrations.    In  one  very  handsome  octavo  volume,  leather,    pp.  566. 

S3  GO. 

In  publishing  the  first  edition  of  this  work,  its  title  was  altered  from  that  of  the  London  volume, 
by  the  substitution  of  the  word  "  Elements"  for  that  of  "  Manual,"  and  with  the  author's  sanction 
the  title  of  "  Elements"  is  still  retained  as  being  more  expressive  of  the  scope  of  the  treatise. 

To  say  that  it  is  the  best  manual  of  Physiology  |  Those  who  have  occasion  for  an  elementary  trea- 
now  before  the  public,  would  notdo  sufficient  justice  i  tise  on  Physiology,  cannot  do  better  than  to  possess 
to  the  author. — Buffalo  Medical  Journal.  themselvesofthemanual  of  Dr.  Carpenter. — Medical 

In  his  former  works  it  would  seem  that  he  had    Examiner. 
exhausted  the  subject  of  Physiology.  In  the  present.       The  best  and  most  complete  expose  of  modern 
hegives  the  essence,  as  it  were,  of  the  whole. — N.  Y.\  Physiology,  in  one  volume,  extant  in  the  English 
Journal  of  Medicine.  \  language. — St.  Louis  Medical  Journal. 

BY  THE  SAME  AUTHOR.     (Preparing.) 

PRINCIPLES  OF   GENERAL   PHYSIOLOGY,    INCLUDING   ORGANIC 

CHEMISTRY  AND  HISTOLOGY.     With   a  General  Sketch  of  the  Vegetable  and  Animal 
Kingdom.    In  one  large  and  very  handsome  octavo  volume,  wilh  several  hundred  illustrations. 
The  subject  of  general  physiology  having  been  omitted  in  the  last  editions  of  the  author's  "  Com- 
parative Physiology"  and  "Human  Physiology,"  he  has  undertaken  to  prepare  a  volume  which 
shall  present  it  more  thoroughly  and  fully  than  has  yet  been  attempted,  and  which  may  be  regarded 
as  an  introduction  to  his  other  works. 

BY  THE  SAME   ATTTHOR. 

A  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN  HEALTH 

AND  DISEASE.     New  edition,  with  a  Preface  by  D.  F.  Condie,  M.  D.,  and  explanations  of 
scientific  words.    In  one  neat  12mo.  volume,  extra  cloth,    pp.  178.     50  cents. 


ISIjAJNUHAlti;    «    JjJiA'S   MiiUlUALi 


CONDIE  (D.  F.),  M.  D.,  Ac. 
A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN.    Fifth 

edition,  revised  and  augmented.    In  one  large  volume,  8vo.,  leather,  of  over  750  pages.  ^3  25. 
(Just  Issued,  1859.) 

In  presenting  a  new  and  revised  edition  of  this  favorite  work,  the  publishers  have  only  to  state 
that  the  atithor  has  endeavored  to  render  it  in  every  respect  "a  complete  and  faithful  exposition  of 
the  patholoiry  and  therapeutics  of  the  maladies  incident  to  the  earlier  stages  of  existence — a  full 
and  exact  account  of  the  diseases  of  infancy  and  childhood."  To  acccmplish  this  he  has  subjected 
the  whole  work  to  a  careful  and  thorough  revision,  rewriting  a  considerable  portion,  and  adding 
several  new  chapters.  In  this  manner  it  is  hoped  that  any  deficiencies  which  may  have  previously 
existed  have  been  supplied,  that  the  recent  labors  of  practitioners  and  observers  have  been  tho- 
roughly incorporated,  and  that  in  every  point  the  work  will  Ije  found  to  maintain  the  high  reputation 
it  has  enjoyed  as  a  complete  and  thoroughly  practical  book  of  reierence  in  infantile  affections. 

A  few  notices  of  previous  editions  are  subjoined. 

Dr.  Condie's  scholarship,  acumen,  industry,  and 
practical  sense  are  manifested  in  this,  as  in  nil  his 
numerous  contributions  to  science. — t)T.  Holmes^s 


Hfport  to  the  American  Medical  Association. 

Taken  as  a  whole,  in  our  judgment.  Dr.  Condie's 
Treatise  is  the  one  from  the  perusal  of  which  the 
practitioner  in  this  country  will  rise  with  the  great- 
est satisfaction. — Western  Journal  of  Medicine  and 
Surgery. 

One  of  the  best  works  upon  the  Diseases  of  Chil- 
dren in  the  English  language. — Western  Lancet. 

We  feel  assured  from  actual  experience  that  no 
physicinn's  library  can  be  complete  without  a  copy 
of  this  work.— iV.  y.  Journal  of  Medicine. 


We  pronounced  the  first  edition  to  be  the  best 
work  on  the  diseases  of  children  in  the  English 
language,  and,  notwithstanding  all  that  has  heen 
published,  we  still  regard  it  in  that  light. — Medical 
Examiner. 

The  value  of  works  by  native  authors  on  the  dis- 
eases which  the  physician  is  called  upon  to  combat, 
will  be  appreciated  by  all ;  anl  the  work  of  Dr.  Con- 
die  has  gained  for  itself  the  character  of  a  safe  guide 
for  students,  and  a  useful  work  for  consultation  by 
those  engaged  in  practice. — N.  Y.  Med.  Times. 

This  is  the  fourth  edition  of  this  deservedly  popu- 
lar treatise.    During  the  interval  since  the  last  edi- 


tion, it  has  been  subjected  to  a  thorough  revision 
.^  ,,  ,•   .  ■  ,         ..  ,       ,  by   the  author;    and   all  new  observations  in   the 

■^ItVil^ni^.rf/iitlVufJi^ZtL^P^nr-^  ^""^  therapeutics  of  children  have  been 

mori>.nn  ino,  1/.0     ■  oiro  „r^      Olito  Mcdicul  and    includcd  in  tlie  present  volume.    As  we  said  btfore, 


to  American  medical  literature 
Surgical  Journal 

We  feel  persuaded  that  the  American  medical  pro- 
fession will  soon  regard  it  not  only  as  a  very  good, 
but  as  the  very  best  "Practical  Treatise  on  the 
Diseases  of  Children." — American  Medical  Journal. 

In  the  department  of  infantile  therapeutics,  the 
work  of  Dr.  Condie  is  considered  one  of  the  best 
which  has  been  published  in  the  English  language. 
—  The  Stethoscope, 


we  do  not  know  of  a  better  book  on  diseases  of  chil- 
dren, and  to  a  large  part  of  its  recommendations  we 
yield  an  unhesitating  concurrence. — Buffalo  Med. 
Journal. 

Perhaps  the  most  full  and  complete  work  now  be- 
fore the  profession  of  the  United  States;  indeed,  we 
may  say  in  the  English  language.  It  is  vastly  supe- 
rior to  most  of  its  predecessors. — Transi/lvaniaMtd. 
Journal. 


CHRISTISON  (ROBERT),  M.  D.,  V.  P.  R.  S.  E.,  Ac. 
A  DISPENSATORY;  or.  Commentary  on  the  Pharmacopoeias  of  Great  Britain 

and  the  United  States;  comprising  the  Natural  History,  Description,  Chemistry,  Pharmacv,  Ac- 
tions, Uses,  and  Doses  of  the  Articles  of  the  Materia  Medica.  Second  edition,  revised  and  im- 
proved, with  a  Supplement  containing  the  most  important  New  Remedies.  With  copious  Addi- 
tions, and  two  hundred  and  thirteen  large  wood-engravings.  By  R.  Eglesfeld  Griffith,  M.  D. 
In  one  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  of  over  1000  pages.  $3  50. 

COOPER  (BRANSBY   BJ,  F.  R.  S. 
LECTURES  ON  THE   PRINCIPLES   AND   PRACTICE  OF   SURGERY. 

In  one  very  large  octavo  volume,  extra  cloth,  of  750  pages.    $3  00. 


COOPER  ON  DISLOCATIONS  AND  FRAC- 
TURES OF  THE  JOINTS.— Edited  by  Brassbt 
B.  Cooper,  F.  R.  S.,  &c.  With  additional  Ob- 
servations by  Prof.  J.  C.  Warren.  A  new  Ame- 
rican edition.  In  one  handsome  octavo  volume, 
extra  cloth,  of  about  500  pages,  with  numerous 
illustrations  on  wood.    $3  25. 

COOPER  ON  THE  ANATOMY  AND  DISEASES 
OF  THE  BREAST,  with  twenty-five  .Miscellane- 
ous and  Surgical  Papers.  One  large  volume,  im- 
perial 8vo.,' extra  cloth,  with  252  figures,  on  38 
plates.    *2  50. 

COOPER  ON  THE  STRUCTURE  AND  DIS- 
EASES OF  THE  TESTIS,  AND  ON  THE 
THYMUS  GLAND.  One  vol.  imperial  i-vo.,  ex- 
tra cloth,  with  177  figures  on  29  plates.    £2  00. 


COPLAND  ON  THE  CAUSES,  NATURE,  AND 
TREATMExNT  OF  PALSY  AND  APOPLEXY. 
In  one  volume,  royal  12mo.,  extra  cloth,  pp.326. 
60  cents. 

CLYMER  ON  FEVERS;  THEIR  DIAGNOSIS, 
PATHOLOGY,  A.ND  TREAT.MENT  In  one 
octavo  volume,  leather,  of  600  pages.    ?1  50. 

COLO.MBAT  DE  L'ISERE  ON  THE  DISEASES 
OF  FEMALES,  and  on  the  special  Hygiene  of 
their  Sex.  Translated,  with  many  "Votes  and  Ad- 
ditions, by  C.  D.  Meigs,  M.D.  Second  edition, 
revised  and  improved.  In  one  large  volume,  oc- 
tavo, leather,  with  numerous  wood-cuts.  pp.  720. 
S3  50. 


CARSON  (JOSEPH),  M.  D., 

Professor  of  Materia  Medica  and  Pharmacy  in  the  University  of  Pennsylvania. 

SYNOPSIS  OF  THE  COURSE  OF  LECTURES  ON  MATERIA  MEDICA 

AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.    Second  and  revised  edi- 
tion.   In  one  very  neat  octavo  volume,  extra  cloth,  of  208  pages.    $1  50. 


CURLING    (T.    B.),    F.  R.S., 

Surgeon  to  the  London  Hospital,  President  of  the  Hunterian  Society,  Ac. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  TESTIS,  SPERMA- 

TIC  CORD,  AND  SCROTUM.    Second  American,  from  the  second  and  enlarged  English  edi- 
tion.   In  one  handsome  octavo  volume,  extra  cloth,  with  numerous  illustrations,  pp.  4".>0.  S2  00. 


AND    SCIENTIFIC    PUBLICATIONS. 


CHURCHILL  (FLEETWOOD),  M.  D.,  M.  R.  I.  A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.     A  new  American 

from  the  fourth  revised  and  enlarged  London  editioti.     With  Notes  and  Additions,  by  D.  Francis 

UoNDiE,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Children,"  &c.     With  191 

illustrations.     In  one  very  handsome  octavo  volume,  leather,  of  nearly  700  large  pages.     $3  50. 

(Now  Ready,  October,  ISGO.) 

This  work  has  been  so  long  an  established  favorite,  both  as  a  text-book  for  the  learner  and  as  a 
reliable  aid  in  consultation  ibr  the  practitioner,  that  in  presenting  a  new  edition  it  is  only  necessary 
to  call  atlention  to  the  very  extended  improvements  which  it  has  received.  Having  had  the  benefit 
of  two  revisions  by  the  author  since  the  last  American  reprint,  it  has  been  materially  enlarged,  and 
Dr.  Churchill's  well-known  conscientious  industry  is  a  guarantee  that  every  portion  has  been  tho- 
roughly brought  up  with  the  latest  results  of  European  investigation  in  all  departments  of  the  sci- 
ence and  art  of  obstetrics.  The  recent  dale  of  the  last  Dublin  edition  has  not  left  much  of  novelty 
for  the  American  editor  to  introduce,  but  he  has  endeavored  to  insert  whatever  has  since  appeared, 
together  wilh  such  matters  as  his  experience  has  ^hown  him  would  be  desirable  lor  the  Amsrican 
student,  including  a  large  number  of  illustrations.  Wilh  the  sanction  of  the  author  he  has  added 
in  the  lorm  of  an  appendix,  some  chapters  from  a  little  -'Manual  tor  Midwives  and  Nurses,"  re- 
cently issued  by  Dr.  Churchill,  believing  that  the  details  there  presented  can  hardly  fail  to  prove  of 
advantage  to  the  junior  practitioner.  Tne  result  of  all  these  additions  is  that  the  work  now  con- 
tains fully  one-half  more  matter  than  the  last  American  edition,  with  nearly  one-half  more  illus- 
trations, so  that  nitwilhstanding  the  use  of  a  smaller  type,  the  volume  contains  almost  two  hundred 
pages  more  than  before. 

No  elfort  has  been  spared  to  secure  an  improvement  in  the  mechanical  execution  of  the  work 
equal  to  ihat  which  the  text  has  received,  and  the  volume  is  confidently  presented  as  one  of  the 
handsomest  that  has  tlnis  far  been  laid  before  the  American  profession;  while  the  very  low  price 
at  which  it  is  olfered  should  secure  for  it  a  place  in  every  lecture-room  and  on  every  office  table. 

A  better  book  in  which  to  learn  these  important        The  most  popular  work  on  midwifery  ever  issued 


poinls  we  have  not  met  than  Dr.  Churchill's.  Every 
page  of  it  is  full  ot"  instruction;  the  opinion  of  all 
writers  of  authority  is  given  on  questions  of  diffi- 
culty, as  well  !is  tlie  directions  and  advice  ot  the 
learned  autiior  himself,  to  which  he  adds  the  result 
of  statibtical  inquiry,  putting  statistics  in  tlieir  pro 
per  place  and  giving  them  their  due  weight,  and  no 
more.  We  have  never  read  a  book  more  free  from 
professional  jealousy  than  Dr.  Churchill's.  It  ap- 
pears to  be  written  with  the  true  design  of  a  hook  on 
medicine,  viz  :  to  give  all  that  is  known  on  the  sub- 
ject of  which  he  treats,  both  theoretically  and  prac- 
tically, and  to  advance  such  opinions  of  his  own  as 
he  believes  will  benefit  medical  science,  and  insure 
the  safety  of  the  patient.  We  have  said  enough  to 
convey  to  the  profession  that  this  book  of  Dr.  Chur- 
chill's is  admirably  Fuited  for  a  book  of  reference 
for  the  practitioner,  as  well  as  a  text-book  for  the 
student,  and  we  hope  it  may  be  extensively  pur- 
chased amongst  our  readers.  To  them  we  most 
Btrongly  recommend  it.  —  Dublin  Medical  Press, 
June  20,  1S60. 

To  bestow  praise  on  a  book  that  has  received  such 
marked  approbation  would  be  superfluous.  We  need 
only  say,  therefore,  that  if  the  first  edition  was 
thought  worthy  of  a  favorable  reception  by  the 
medical  public,  we  can  confidently  affirm  that  this 
will  be  found  much  more  so.  The  lecturer,  the 
practitioner,  and  the  student,  may  all  have  recourse 
to  its  pages,  and  derive  from  their  perusal  much  in- 
terest anri  instruction  in  everything  relating  to  theo- 
retical and  practical  midwifery. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  work  of  very  great  merit,  and  such  as  we  can 
confidently  recommend  to  the  study  of  every  obste- 
tric practitioner. — London  Medical  Gazette. 

This  is  certainly  the  most  perfect  system  extant. 
It  is  the  best  adapted  for  the  purposes  of  a  text- 
book, and  that  which  he  whose  necessities  confine 
him  to  one  book,  should  select  in  preference  to  all 
others. — Soutkem  Medical  and  Surgical  Journal. 

BY  THE  SAME  AUTHOR.     (Lately  Puhlixlied.) 

ON  THE  DISEASES  OF  INFANTS  AND  CHILDREN.     Second  Araerican 

Edition,  revised  and  enlarged  by  the  author.  Edited,  with  Notes,  by  W.  V.  Kkati.ng,  M.  D.  In 
one  large  and  handsome  volume,  extra  cloth,  of  over  700  pages.  $3  00,  or  in  leather,  S3  25. 
In  preparing  this  work  a  second  time  for  the  American  profession,  the  author  has  spared  no 
labor  in  giving  it  a  very  thorough  revision,  introducing  several  new  chapters,  and  rewriting  others, 
while  every  portion  of  the  volume  has  been  subjected  to  a  severe  scrutiny.  The  efforts  of  the 
American  editor  have  l)een  directed  to  supplying  such  information  relative  to  matters  peculiar 
to  this  country  as  might  have  escaped  the  attention  of  the  author,  and  the  whole  may,  there- 
fore, be  safely  pronounced  one  of  the  most  complete  works  on  the  subject  accessible  to  the  Ame- 
rican Profession.  By  an  alteration  in  the  size  of  the  page,  these  very  extensive  additions  have 
been  accommodated  without  imduly  increasing  the  size  of  the  work. 

BY  THE  SAME   AUTHOR. 

ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DISEASES  PE- 

CULIAR  TO  WOMEN.    Selected  from  the  wrilingsof  British  Aiilhors  previous  to  the  close  of 
the  Eighteenth  Century.    In  one  neat  octavo  volume,  extra  cloth,  of  about  450  pages.    $2  50. 


from  the  American  press. — Charleston  Med.  Journal. 
Were  we  reduced  to  the  necessity  of  having  but 
tne  work  on  midwifery,  and  jterinitted  to  choose, 
we  would  unhesitatingly  take  Churchill. — Western 
Med.  and  Surg.  Journal. 

It  is  impossible  to  conceive  a  more  useful  and 
slegant  manual  than  Dr.  Churchill's  Practice  of 
Midwifery. — Provincial  Medical  Journal. 

Certainly,  in  our  opinion,  the  very  best  work  on 
he  subject  which  exists. — N.  Y.  Annalist. 

No  work  holds  a  higher  position,  or  is  more  de- 
serving of  being  placed  in  the  hands  of  th'.-  tyro, 
the  advanced  student,  or  the  practitionei;. — Medical 
Examiner. 

Previous  editions,  under  the  editorial  supervision 
of  Prof  R.  M.  Huston,  have  been  received  with 
marked  favor,  and  they  deserved  it;  but  this,  re- 
printed from  a  very  late  Dublin  edition,  carefully 
revised  and  brought  up  by  the  author  to  the  present 
time,  does  present  an  unusually  accurate  and  able 
exposition  of  every  important  particular  embraced 
in  the  department  of  midwifery.  *  *  Theclearn^£j 
directness,  and  precision  of  its  teachings,  together 
with  the  great  amount  of  statistical  research  which 
its  text  exhibits,  have  served  to  place  it  already  in 
the  foremost  rank  of  works  in  this  department  of  re- 
medial science. — N.  O.  Med.  and  Surg.  Journal. 

In  our  opinion,  it  forms  one  of  the  best  if  not  the 
very  best  text-book  and  epitome  of  obstetric  science 
which  we  at  present  possess  in  the  English  lan- 
guage.— Monthly  Journal  of  Medical  Science. 

The  clearness  and  precision  of  style  in  which  it  is 
written,  and  the  great  amount  of  statistical  research 
which  it  contains,  have  served  to  place  it  in  the  first 
rank  of  works  in  this  departmentof  medical  science. 
—N.  Y.  Journal  of  Medicine. 

Few  treatises  will  be  found  better  adapted  as  a 
text-book  for  the  student,  or  as  a  manual  for  the 
frequent  consultation  of  the  young  practitioner. — 
American  Medical  Journal. 


10  BLANCHARD    &    LEA'S   MEDICAL 


CHURCHILL  (FLEETWOOD),    M .  D.,  M .  R,  L  A.,    fee 

ON  THE  DISEASES  OF  WOMEN;  including  those  of  Pregnancy  and  CiiUd- 

bed.    A  new  American  edition,  revised  by  Ihe  Author.    With  Notes  and  Additions,  bv  D  Fran- 
cis CoNDiE,  M.  D.,  author  ot  "A  Practical  Treatise  on  the  Diseases  of  Children."    With  nume- 
rous illustrations.    In  one  large  and  handsome  octavo  volume,  leather,  of  768  pages.    S.3  00. 
This  edition  of  Dr.  Churchill's  very  popular  treatise  mav  almost  be  termed  a  new  work,  so 
thoroughly  has  he  revised  it  in  every  portion.     It  will  be  found  greatly  enlarged,  and  completely 
brought  up  to  the  most  recent  condition  of  the  subjeot,  while  the  verv  handsome  series  ol  illustra- 
tions introduced,  representing  such  pathological  conditions  as  can  be  accurately  portrayed,  present 
a  novel  feature,  and  afford  valuable  assistance  to  the  young  practitioner.     Such  addiiions  as  ap- 
peared desirable  for  the  American  student  have  been  made  by  the  editor,  Dr.  Condie,  while  a 
marked  improvement  in  the  mechanical  execution  keeps  pace  with  the  advance  in  all  other  respects 
which  the  volume  has  undergone,  while  the  price  has  been  kept  at  the  former  very  moderate  rate. 
It  comprises,  unquestionably,  one  of  the  most  ex-  '  extent  that  Dr.  Churchill  does.    His,  indeed,  is  the 
act  and  comprehensive  expositions  of  the  present    only  thorough  treatise  we  know  of  on  the  subject: 
state  of  medical  knowledge  in  respect  to  the  diseases    and'  it  may  he  commended  to  practitioners  and  stu- 
of  women  that  has  yet  been  published.— jlwi.  Journ.    dents  as  a  masterpiece  in  its  particular  department. 
Med.  Sciences,  July,  1657.  —Thi  Western  Journal  of  Medicine  and  Surgery. 

This  work  is  the  most  reliable  which  we  possess  As  a  comprehensive  manual  for  students,  or  a 
on  this  subject;  and  is  deservedly  popular  with  the  ,  work  of  reference  for  practitioners,  it  surpasses  any 
profession.— CAnrieiion  Med.  Journal,  July,  1857.        other  tliat  has  ever  issued  on  the  same  subject  from 

We  know  of  no  author  who  deserves  that  appro-     the  British  press. — Dublin  Quart.  Journal. 
batioo,  on  "the  diseases  of  females,"  to  the  same  i 


DICKSON   (S.    H.),    M.  D., 

Professor  of  Practice  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

ELEMENTS  OF  MEDICINE;   a  Compendious  View  of  Pathology  and  Thera- 

peutics,  or  the  History  and  Treatment  of  Diseases.     Second  edition,  revised.     In  one  large  and 
handsome  octavo  volume,  ol  750  pages,  leather.     $3  75.     {Just  Issued.) 

The  steady  demand  which  has  so  soon  exhausted  the  first  edition  of  this  work,  sufficiently  shows 
that  the  author  was  not  mistaken  in  supposing  that  a  volume  of  this  character  was  needed — an 
elementary  manual  of  practice,  which  should  present  the  leading  principles  of  medicine  with  the 
practical  results,  in  a  condensed  and  perspicuous  manner.  Disencumbered  of  unnecessary  detail 
and  fruitless  speculations,  it  embodies  what  is  most  requisite  for  the  student  to  learn,  and  at  the 
saiiie  lime  what  the  active  practitioner  wants  when  obliged,  in  the  daily  calls  of  his  profession,  to 
refresh  his  memory  on  special  points.  The  clear  and  attractive  style  of  the  author  renders  the 
whole  ea>-y  of  comprehension,  while  his  long  experience  gives  to  his  teachings  an  authority  every- 
where acknowledged.  Few  physicians,  indeed,  have  had  wider  opportunities  for  obser\-ation  and 
experience,  and  lew,  perhaps,  have  used  them  to  better  purpose.  As  the  result  of  a  long  life  de- 
voied  to  study  and  practice,  the  present  edition,  revised  and  brought  up  to  the  date  of  publication, 
will  doubtless  maintain  the  reputation  already  acquired  as  a  condensed  and  convenient  American 
text-book  on  the  Practice  of  Medicine. 


DRUITT   (ROBERT),   M.R.  C.S.,   fitc. 
THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY.     A  new 

and  revised  American  from  the  eighth  enlarged  and  improved  London  edition.  Illustrated  with 
four  hundred  and  thirty-two  wood-engravings.  In  one  very  handsomely  printed  octavo  volume, 
leather,  of  nearly  700  large  pages.     $3  50.     {Now  Ready,  October,  1560.) 

A  work  which  like  Druitt's  Surgery  has  for  so  many  years  maintained  the  position  of  a  lead- 
ing favorite  with  all  classes  of  the  profession,  needs  no  special  recommendation  to  attract  attention 
to  a  revised  edition.  It  is  only  necessary  to  state  that  the  auilior  has  spared  no  pains  to  keep  the 
work  up  to  its  well  earned  reputation  of  presenting  in  a  small  and  convenient  compass  the  latest 
condition  of  every  department  of  surgery,  considered  both  as  a  science  and  as  an  art;  and  that  the 
services  of  a  competent  American  editor  have  been  employed  to  introduce  whatever  novelties  may 
have  escaped  the  author's  attention,  or  may  prove  of  service  to  the  American  practitioner.  As 
several  editions  have  appeared  in  London  since  the  issue  of  the  last  American  reprint,  the  volume 
has  had  the  benefit  of  repeated  revisions  by  the  author,  resulting  in  a  very  tnorough  alteration  and 
improvement.  The  extent  of  these  addiiions  may  be  estimated  from  the  tact  that  it  now  contains 
about  one-third  more  matter  than  the  previous  American  edition,  and  that  notwithstanding  the 
adoption  of  a  smaller  type,  the  i)ages  have  been  increa.sed  by  about  one  hundred,  while  nearly  two 
hundred  and  fifty  wood-cuts  have  been  added  to  the  former  list  of  illustrations. 

A  marked  iiuprovement  will  also  be  perceived  in  the  mechanical  and  artisiical  execution  of  the 
work,  which,  printed  in  the  I^est  style,  on  new  t\pe,  and  fine  pajM?r,  leaves  little  to  be  desired  as 
regards  external  finish;  while  at  the  very  low  price  allixed  it  will  be  found  one  of  the  cheapest 
volumes  accessit)le  to  the  profession. 

This  popular  volume,  now  a  most  comprehensive  nothing  of  real  practical  importance  has  been  omit- 
work  in  surgery,  has  undergone  many  corrections,  ted;  it  presents  a  faithful  epitomeofeveryihing  re- 
improvements,  and  additions,  and  the  principles  and  lating  t  >  surgery  up  to  the  present  hour.  It  is  de- 
the  practice  of  the  art  have  been  brought  down  to  servedly  a  popular  manual,  both  with  the  student 
the  latest  record  and  observation.  Of  the  operations  and  practitioner.— Lcnt^on  Lancet,  Nov.  19,  11^59. 
in  surgery  it  is  inipoKsitile  to  (peak  too  highly.     The        t      i     •        u-    v.  •   /.        •  i 

defcripiionsare  so  char  and  concise,  and  the  illus-  '"  closing  this  brief  notice,  we  recommend  as  cor- 
trations  so  ascurale  and  numerous,  that  the  student  '''""^'  »«  "^^^  *•"«  "'"*'  useful  and  comprehensive 
can  have  no  difficulty,  with  instrument  in  hand,  and  hand-book.  It  must  prove  a  vast  assibtance,  not 
bcok  bv  his  side,  over  the  dead  body,  in  obtaining  ""'>"  to  the  student  of  surgery,  but  also  to  the  busy 
a  proper  knowledge  and  sufficient  tact  in  this  much  Pmctitiooer  whi  may  not  have  the  leisure  to  devote 
neplectrddepiirimentofmedicaleducation.— /Jria'iA  '"mBelf  to  the  study  of  more  lengthy  volumes.— 
and  Forrign  Midico-ckirurg.  Review,  Jan.  ISCO.         London  Med.  Times  and  Gazette,  Oct.  22,  1S59. 

In  the  present  edition  the  author  has  entirely  re-  In  a  word,   this  eighth   edition   of  Dr.  Sruitl's 

wriiien  many  of  the  chapters,  and  has  incorporated  Manual  of  Surgery  is  all  that  the  surgical  student 

the  various  iraprovemenis  and  addiiions  in  modern  or   practitioner  could   desire.  —  Dublin   Quarterly 

surgery.    On  carefully  going  over  it,  we  find  that  Journal  of  Mtd.  Sciences,  Nov.  1659. 


AND    SCIENTIFIC    PUBLICATIONS. 


11 


DALTON,  JR.  (J.   C),   M.  D. 

Professor  of  Pliysiology  in  tlie  College  of  Physicians,  New  York. 

A  TREx\TISE  ON  HUMAN  PHYSIOLOGY,  designed  for  the  use  of  Students 

and  Prart  it  loners  of  Medicine.  With  two  hundred  and  fit'ty-foiir  illustrations  on  wood.  In  one 
very  beautiful  octavo  volume,  of  over  600  pages,  extra  cloth,  $4  00 ;  leather,  raised  bands,  $4  25. 
(Just  Issued.) 


This  system  of  Physiology,  both  from  the  ex- 
cellence of  the  arrrtngement  studiously  observed 
throughout  every  page,  and  the  clear,  Im-id,  and  in- 
structive manner  in  which  each  subject  is  treated, 
promises  to  form  one  of  the  most  generally  received 
class-books  in  the  Knglish  languajie.  It  is,  m  fact, 
a  most  admirable  epitome  of  all  the  really  jmporlant 
discoveries  thai  have  always  been  received  as  incon- 
testable truths,  as  well  us  of  those  wliich  have  been 
recently  added  to  our  stock  of  knowledge  on  this  sub- 
ject. We  will,  however,  proceed  to  give  a  few  ex-  i 
tracts  from  the  book  itself,  as  a  specimen  of  its  style 
and  composition, and  this,  weconceive,  will  bequite 
sufficient  to  awaken  a  general  interest  in  a  work 
which  isimmeasiirabl)  superior  in  its  details  to  the 
majority  of  those  of  the  same  class  t'l  which  it  be- 
longs. In  its  purity  of  style  and  elegance  of  com- 
position it  m-iy  safely  take  its  place  with  the  very 
best  of  our  Knglish  classics;  while  in  accuracy  of 
cte8cripti(m  it  is  impossible  that  it  could  be  surpass 
ed.  In  every  line  is  beautifully  shadowed  forth  the 
emanations  of  the  poliBhcd  scholar,  whose  rellec- 
tions  are  clothed  in  a  garb  as  interesting  as  they  are 
impressive;  with  the  one  predominant  feeling  ap- 
pearing to  pervade  the  whole — an  anxious  desire  to 
please  and  at  the  same  time  to  instruct. —  Dublin 
Quarterly  Journ.  of  Med.  Sciences,  Nov.  1859. 

The  work  before  us,  however,  in  our  humble  judg- 
ment, is  precisely  what  it  purports  to  be,  and  will 
answer  admirably  the  purpose  for  which  it  is  in- 
tended. It  is  par  excellence,  a.  text-book;  and  the 
best  text-book  in  tl  is  department  that  we  have  ever 
Been.  We  have  carefully  read  tlie  book,  and  speak 
of  its  merits  from  a  more  than  cursory  perusal. 
Looking  back  upon  the  work  we  have  just  finished, 
we  must  say  a  word  concerning  the  excellence  of  its 
illustrations.  No  department  is  so  dependent  upon 
good  illustrations,  and  those  which  keep  pace  with 
our  knowledge  of  the  subject,  as  that  of  physiology. 
The  wo<id-cuts  in  the  work  before  us  are  the  best 
we  have  ever  seen,  and,  being  original,  serve  to 
illustrate  precisely  what  is  desired  — Buffalo  Med. 
Journal,  March,  1859. 

A  book  of  genuine  merit  like  this  deserves  hearty 
praise  before  subjecting  it  t.)  any  minute  criticism. 
We  are  not  prepared  to  find  any  fault  with  its  design 
until  we  have  had  more  time  to  appreciate  its  merits 
as  a  manual  for  daily  consultation,  and  to  weigh 
its  statements  and  conclusions  more  deliberatelv. 
Its  excellences  we  are  sure  of;  its  defects  we  have 
yet  to  discover.     It  is  a  work  highly  honorable  to 


its  author;  to  his  talents,  his  industry,  his  training: 
to  the  institution  with  which  he  is  connected,  ana 
to  American  science. — Boston  Med.  and  Surgical 
Journal,  Feb.  24,  1859. 

A  NEW  book  and  a  fi  rst  rate  one ;  an  original  book, 
and  one  wliich  cannot  be  too  highly  a|)preciated, 
and  which  we  are  proud  to  see  emanating  from  our 
country's  press.  It  is  by  an  author  who,  though 
young,  is  considerably  fiimous  for  physiological  re- 
search, and  who  in  this  work  has  erected  for  him- 
self an  enduring  monument,  a  token  at  once  of  his 
labor  and  liis  success. — Nashville  Medical  Journal^ 
March,  1859. 

Throughout  the  entire  work,  the  definitions  are 
clear  and  precise,  the  arrangement  admirable,  the 
argument  !)rie(iy  and  well  stated,  and  the  style 
nervous,  simple,  and  concise.  Section  third,  treat- 
ing of  Reproduction,  is  a  monograph  of  unap- 
proached  excellence,  upon  this  subject,  in  the  Eng- 
lish tongue.  For  precision,  elegance  and  force  of 
style,  exhaustive  method  and  extent  of  treatment, 
fulness  of  illustration  and  weight  of  personal  re- 
search, we  know  of  no  Ameri  -an  contribution  to 
medical  science  which  surpasses  it,  and  the  day  is 
far  distant  when  its  claims  to  the  respectful  atten- 
tion of  even  the  best  informed  scholars  will  not  be 
cheerfully  conceded  by  all  acquainted  with  its  range 
ana  depth. — Charleston  Med.  Journal,  May,  1859. 

A  new  elementary  work  on  Human  Physiology 
lifting  up  its  voice  in  tlie  presence  of  hue  and  sturdy 
editions  of  Kirke's,  Carpenter's,  Todd  and  Bow- 
man's, to  say  nothing  of  Duiglison's  and  Draper's, 
should  have  something  superior  in  the  matter  or  the 
manner  of  its  utterance  in  order  to  win  for  itself 
deserved  attention  and  a  name.  Tiiat  maiter  and 
that  manner,  alter  a  candid  perusal,  we  think  dis- 
tinguish this  work,  and  we  are  proud  to  welcome  it 
not  merely  for  its  nativity's  sake,  but  for  iis  own 
intrinsic  excellence.  Its  language  we  find  to  be 
plain,  direct,  unambitious,  and  falling  with  a  just 
conciseness  on  hypothetical  or  unsetiltd  questions, 
and  yet  with  sufficient  fulness  on  those  living  topics 
already  understood,  or  the  path  to  whose  solution 
is  definitely  marked  out.  It  does  not  speak  exhaust- 
i  /ely  upon  every  subject  that  it  notices,  but  it  does 
speak  suggestively,  experimentally,  and  to  their 
main  utiliiies.  Into  the  subject  of  Reproduction 
our  author  plunges  with  a  kind  of  loving  spirit. 
Thriughout  ttiislnteresting  and  obscure  department 
he  is  a  clear  and  admirable  teacher,  sometimes  a 
brilliant  leader. — Am.  Med.  Monthly,  May,  ls59. 


DUNGLISON,    FORBES,   TWEEDIE,    AND   CONOLLY. 
THE  CYCLOPEDIA  OF  PRACTICAL  MEDICINE:  comprising  Treatises  on 

the  Nature  and  Treatment  of  Diseases,  Materia  Medica,  and  Therapeutics,  Diseases  of  Women 

and  Children,  Medical  Jurisprudence,  &c.  &c.      in  four  large  super-royal  octavo  volumes,  of 

3254  double-columned  pages,  strong-ly  and  handsomely  bound,  with  raised  bands.     $12  00. 

*^*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  Ireati.ses,  contributed  by 
eixty-eight  distinguished  physicians,  rendering  it  a  complete  library  of  reference  for  the  country 
practitioner. 

The  most  complete  work  on  Practical  Medicine  titioner.  This  estimate  of  it  has  not  been  formed 
extant;  or,  at  least,  in  our  language.— £u^'a/o  from  a  hasty  examination,  but  after  an  intimate  ac- 
Medical  and  Surgical  Journal.  quaintance  derived  from  frequent  c<msultation  of  it 

„  .  ..  ■      I  11       •      »  _     during  the  past  nine  or  ten  years.     The  editors  are 

For  reference,  it  is  above  all  price  to  every  prac-  pr^etftioners  of  established  reputati.m,  and  the  list 
titioner.— Western  l^ancet.  of  contributors  embraces  many  of  the  most  eminent 

One  of  the  most  valuable  medical  publications  of  professorsand  teachers  of  London,  Kdinburgh,  Dub- 
theday — as  a  work  of  reference  it  is  invaluable. —  Un,  and  Glasgow.  It  is,  indeed,  the  great  merit  of 
Western  Journal  oj  Medicine  and  Surgery.  this  work  that  the  principal  articles  have  been  t'ur- 

It  has  been  to  us,  both  as  learner  and  teacher,  a  nisheU  by  practitioners  who  have  not  only  ilevoted 
work  for  ready  and  frequent  reference,  one  In  which  cspecialattention  to  the  diseases  about  which  they 
modern  Knglish  medicine  is  exhibited  in  the  most  have  written,  but  have  also  enjoyed  opportunities 
advantageous  light.— Medical  Examiner.  f"r  ""  extensive  practical  acquaintance  with  them, 

and  whose  reputation  carries  the  assurance  of  their 

We  rejoice  that  this  work  is  to  be  placed  within  i  competency  justly  to  appreciate  the  opinions  of 
the  reach  of  the  profession  in  this  country,  it  being  I  others,  while  it  stamps  their  own  doctrines  with 
unquestionably  one  of  very  great  value  to  tlie  prae-  \  high  and  just  authority. — American  Medical  .Tourn. 


DEWKKS'S  COMPREHENSIVK   SYSTEM   OF  | 
MIDWIFERV.     Illustrated  by  occasional  cases  ' 
and  many  engravings.     Twelfth  edition,  with  the  ■ 
author's  last  improvements  and   correctiims      In 
oneoctavo  volume,  extracloth, of  600 pages.  SJ320.  j 

DEWEES'S  TREATISE  ON  THE  PHYSICAL  I 


AND  MEDICAL  TREATMENT  OF  CHILD- 
RE.N.  The  last  edition.  In  one  volume,  octavo, 
extra  cloth,  518  pages.     82  80 

DEWEES'S  TREATISE  ON  THE  DISEASES 
OF  FEMALES.  Tenth  edition.  In  one  volume, 
octavo   extra  cloth,  532  pages,  with  plates.  S:3  00 


12 


BLANCHARli)    &    LEA'S    MEDICAL 


DUNGLISON    (ROBLEY),    M.D., 

ProfcMor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

NE"W  AND  ENLARGED  EDITION. 

MEDICAL  LEXICON;   a  Dictionary  of  Medical  Science,  containing  a  concise 

Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathology,  Hygiene, 
Therapeutic-6,  PharmacologAS  Pharmacy,  Surgery,  Obstetrics,  Medical  Jurisprudence,  Dentistry, 
&c.  Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for  OlTicinal,  Empirical,  and  Dietetic 
Preparations,  lVtc.  With  French  and  other  Synonymes.  Revised  and  very  greatly  enlarged. 
In  one  very  large  and  handsome  octavo  volume,  of  992  double-columued  pages,  ia  small  type; 
strongly  bound  in  leather,  with  raised  bands.    Price  $4  00. 

Especial  care  has  been  devoted  in  the  preparation  of  this  edition  to  render  it  in  every  re.«pect 
worthy  a  continuance  of  the  very  remarkable  favor  which  it  has  hitherto  enjoyed.  The  rapid 
sale  of  Fifteen  large  editions,  and  the  constantly  increasing  demand,  show  that'll  is  regarded  by 
the  profession  as  the  standard  authority.  Stimulated  by  this  fact,  the  author  has  endeavored  in  the 
present  revision  to  introduce  whatever  might  be  necessary  "to  make  it  a  satisfactory  and  desira- 
ble— if  not  indis()ensal)le — lexicon,  in  which  the  student  may  search  without  disappointment  for 
every  term  that  has  been  legitimated  in  the  nomenclature  of  the  science."  To  accomplish  this, 
large  additions  have  been  foiind  requisite,  and  the  extent  of  the  author's  labors  may  l)e  estimated 
from  the  fact  that  about  Six  Thousand  subjects  and  terms  have  been  introduced  throughout,  ren- 
dering the  whole  number  of  definitions  about  Sixty  Thousand,  to  accommodate  which,  the  num- 
ber of  pages  has  been  increased  by  nearly  a  hundred,  notwithstanding  an  enlargement  in  the  size 
of  the  pase.  The  medical  press,  both  in  this  country  and  in  England,  has  pronounced  the  work  in- 
dispensable to  all  medical  students  and  practitioners,  and  the  present  improved  edition  will  not  lose 
that  enviable  reputation. 

The  publishers  have  endeavored  to  render  the  mechanical  execution  worthy  of  a  volume  of  such 
universal  use  in  daily  reference.  The  greatest  care  has  been  exercised  to  obtain  the  typographical 
accuracy  so  necessary  in  a  work  of  the  kind.  By  the  small  but  exceedingly  clear  type  employed, 
an  immense  amount  o(  matter  is  condensed  in  its  thousand  ample  pages,  while  the  binding  will  be 
found  strong  and  durable.  With  all  these  improvements  and  enlargements,  the  price  has  been  kept 
at  the  former  very  moderate  rate,  placing  it  within  the  reach  of  all. 


This  work,  the  appearance  of  the  fifteenth  edition 
of  which,  it  has  beeome  our  duty  and  pleasure  to 
announce,  is  perhaps  the  most  stupendous  monument 
of  hibor  and  erudition  in  medical  literature.  One 
would  hardly  suppose  after  constant  use  of  the  pre- 
ceding editions,  where  we  have  never  failed  to  find 
a  sufficitntly  full  explanation  of  ever)  medical  term, 
that  in  this  edition  '^  about  six  thousand  subjects 
and  terms  have  been  added,'^  with  a  careful  revision 
and  correcti(m  of  the  entire  work.  It  is  only  nece s- 
sarj-  to  announce  the  advent  of  this  eilition  to  make 
it  occupy  the  place  of  the  preceding  one  on  the  table 
of  every  medical  man,  ns  it  is  without  doubt  the  best 
and  most  comprehensive  work  of  the  kind  which  has 
ever  appeared. — Buffalo  Med.Journ.,  Jan.  1858. 

The  work  is  a  monument  of  patient  research, 
skilful  judgment,  and  vast  physical  labor,  that  will 
perpetuate  the  name  of  the  author  more  etfectually 
than  any  possible  device  of  stone  or  metal.  Dr. 
Dunglison  deserves  the  thanks  not  only  of  the  Ame- 
rican profession,  but  of  the  whole  meilical  world. — 
Aorlh  Am.  Medieo-Chir.  Review,  Jan.  1658. 

A  Medical  Dictionary  better  a<lapted  for  the  wants 
of  the  profession  than  any  other  with  which  we  are 
acquainted,  and  of  a  character  which  places  it  far 
above  comparison  and  competition. — Am.  Joum. 
Med.  Sciences,  Jan.  1858. 

We  need  only  say,  that  the  addition  of  6,000  new 
terms,  with  their  accompanying  definitions,  may  be 
said  to  constitute  a  new  work,  by  itself.  We  have 
eiainined  the  Dictionary  attentively,  and  are  most 
happy  to  pronounce  it  unrivalled  of  its  kind.  The 
erudition  displayed,  and  the  extraordinary  industry 
which  must  have  been  demanded,  in  its  preparation 
and  perfection,  redound  to  tlie  lasting  credit  of  its 
author,  and  have  t'urnished  us  witli  a  volume  indis- 
pensable at  the  present  day,  to  all  who  would  find 
themselves  au  ntveau  with  the  highest  standards  of 
medical  information. — Boston  Medical  and  Surgical 
Journal,  Dec. 31,  1857. 

Good  lexicons  and  encyclopedic  works  generally, 
are  the  most  labor-saving  contrivances  which  lite- 
rary men  enjoy;  and  the  labor  which  is  required  to 
produce  Ihcm  in  the  perfect  manner  of  this  example 
18  something  appalling  to  contemplate.    The  author 


tells  us  in  his  preface  that  he  has  added  about  six 
thousand  terms  and  subjects  to  this  edition,  which, 
before,  was  considered  universally  as  the  best  work 
of  the  kind  in  any  language. — Silliman^s  Journal, 
March,  1858. 

He  has  razed  his  gigantic  structure  to  the  founda- 
tions, and  remodelled  and  reconstructed  the  entire 
pile.  No  less  than  six  thousand  additional  subjects 
and  terms  are  illustrated  and  analyzed  in  this  new 
edition,  swelling  the  grand  aggregate  to  beyond 
sixty  thousand  !  Thus  is  placed  before  the  profes- 
sion a  complete  and  thorough  exponent  of  medical 
terminology,  without  rival  or  possibility  of  rivalry. 
— Nashville  Joum.  of  Med.  and  Surg.,  Jan.  1858. 

It  is  universally  acknowledged,  we  believe,  that 
I  this  work  is  incomparably  the  best  and  most  com- 
plete Medical  Lexicon  in  the  English  language. 
The  amount  of  labor  which  thedistinguished  author 
has  bestowed  upon  it  is  truly  wonderful,  and  the 
learning  and  research  displayed  in  its  preparation 
are  equally  remarkable.  Comment  and  commenda- 
tion are  unnecess;iry,  as  no  one  at  the  present  day 
I  thinks  of  purchasing  any  other  Medical  Dictionary 
than  this. — St.  Louts  Med.  and  Surg.  Journ.,  J&a. 
1658. 

It  is  the  foundation  stone  of  a  good  medical  libra- 
ry', and  should  always  be  included  in  the  first  list  of 
books  purchased  by  the  medical  student. — Am.  Med. 
Monthly,  Jan.  1858. 

A  very  perfect  work  of  the  kind,  undoubtedly  the 
most  perfect  in  the  English  language. — Med.  and 
Surg.  Reporter,  Jan.  1858. 

It  is  now  emphatically  the  Medical  Dictionary  of 
the  English  language,  and  t'or  it  there  is  no  substi- 
tute.— iV.  H.  Med.  Joum.,  Jan.  18.38. 

It  is  scarcely  necessary  to  remark  that  any  medi- 
cal library  wanting  a  copy  of  Duneli8<in's  Lexicon 
must  be  imperfect. — Cin.  Lancet,  Jan.  1858. 

We  have  ever  considered  it  the  best  authority  pub- 
lished, and  the  presenteditiim  we  may  safely  say  has 
no  equ.Tl  in  the  world. — Peninsular  Med.  Journal, 
Jan.  1858. 

The  most  complete  authority  on  the  subject  to  b« 
found  in  any  language. —  Va.Med.  Journal,  Feb.  '58. 


BY   THE  SAME   AUTHOR. 

THE  PRACTICE  OF  MEDICINE.     A  Treatise  on  Special  Pathology  and  The- 
rapeutics.    Third  Edition.    In  two  lai^e  octavo  volumes,  leather,  of  1,500  pages.    $6  25. 


AND    SCIENTIFIC    PUBLICATIONS.  13 

DUNGLISON    (ROBLEY),    M.D., 

Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOGY.  Eighth  edition.  Thoroughly  revised  and  exten- 
sively modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.  In  two  large  and 
handsomely  printed  octavo  volumes,  leather,  of  about  1500  pages.     $7  GO. 

In  revising  this  work  for  its  eighth  appearance,  the  author  has  spared  no  labor  to  render  it  worthy 
a  continuance  of  the  very  great  favor  which  has  been  extended  to  it  by  the  profession.  The  whole 
contents  have  been  rearranged,  and  to  a  great  extent  remodelled;  the  investigations  which  of  late 
years  have  been  so  numerous  and  so  important,  have  been  carefully  examined  and  incorparated, 
and  the  work  in  every  respect  has  been  brought  up  to  a  level  with  the  present  state  of  the  subject. 
The  object  of  the  author  has  been  to  render  it  a  concise  but  comprehensive  treatise,  containing  the 
whole  body  of  physiological  science,  to  which  the  student  and  man  of  science  can  at  all  times  refer 
with  the  certainty  of  finding  whatever  they  are  in  search  of,  fully  presented  in  all  its  aspects;  and 
on  no  former  edition  has  the  author  bestowed  more  labor  to  secure  this  result. 

We  believe  that  it  can  truly  be  said,  no  more  com-  The  best  work  of  the  kind  in  the  English  lao- 
ptete  repertory  of  facts  upon  the   subject  treated,    guage. — Silliman^s  Journal. 

can  any  where 'be  found  The  author  has,  moreover,  T-|,e  present  edition  the  author  has  made  a  pcifcct 
that  enviable  tact  at  description  and  that  facility  mirror  of  the  science  as  it  is  at  the  present  hour, 
and  ease  of  expression  which  render  him  peculiarly  ^s  a  work  upon  phvsiolosry  proper,  the  science  of 
acceptable  to  the  casual,  or  the  studious  reader,  the  functions  performed  bv'^t.he  body,  the  student  will 
This  faculty,  bo  requisite  in  setting  forth  many  gnj  jt  all  he  wishes.— jVasAri//e  Journ.  of  Med. 
praver  and  less  attractive  subjects,  lends  additional        „■    ^i,     i  ■  j  .  ^> 

charms  to  <me  always  fascinating— Boston  Med.\  .  That  he  has  succeeded,  most  admirably  succeeded 
and  Surg  Journal.  '"  his  purpose,  is  apparent  from  the  appearance  of 

an  eighth  e<lition.     It  is  now  the  erreat  encyclopaedia 

The   most  complete  and  satisfactory   system   of    on  the  subject,  and  wortliy  of  a  place  in  every  phy- 
Physiology  in  the  English  language. — Amer.Med.',  sician's  library. —  Western  Lancet. 
Journal .  I 

BY  THE  SAME  AUTHOR.     {A  new  edition.) 

GENERAL    THERAPEUTICS    AND    MATERIA  MEDICA;   adapted  for  a 

Medical  Text-book.  With  Indexes  of  Remedies  and  of  Diseases  and  their  Remedies.  Sixth 
Edition,  revised  and  improved.  With  one  hundred  and  ninety-three  illustrations.  In  two  large 
and  handsomely  printed  octavo  vols.,  leather,  of  about  1100  pages.    S6  00. 

In  announcing  a  new  edition  of  Dr.  Dunglison's  |  The  work  will,  we  have  little  doubt,  be  bought 
General  Therapeutics  and  Materia  Medica,  we  have  I  and  read  by  the  majurity  of  medical  students:  its 
no  words  of  commendation  to  bestow  upon  a  work  \  size,  arrangement,  and  reliability  recommend  it  to 
whose  merits  have  been  heretofore  so  often  and  so  all ;  no  one,  we  venture  to  pretliet,  will  study  it 
justly  extolled.  It  must  not  be  supposed,  however,  j  without  profit,  and  there  are  few  to  whom  it  will 
that  the  present  is  a  mere  reprint  of  the  previous  not  be  in  some  measure  useful  us  a  work  of  refcr- 
edition:  the  character  of  the  author  for  laborious  ence.  The  young  practitioner,  more  especially,  will 
research,  judicious  analysis,  and  clearness  of  ex-  find  the  copious  indexes  appendtd  to  this  ediiion  of 
pression,  is  fuUv  sustained  by  the  numerous  addi-  '  great  assistance  in  the  selection  and  preparation  of 
tions  he  nas  made  to  the  work,  and  the  careful  re-  suitable  formulae. — Charleston  Med.  Journ.  and  Re- 
Vision  to  which  he  has  subjected  the  whole. — A'.  A.  ,  vieio,  Jan.  165s. 
Medico-Chir.  Review,  Jan.  IboS.  > 

BY  THE  SAME   AUTHOR.      (A  lieiO  Editt07l.) 

NEW  REMEDIES,  WITH  FORMULA  FOR  THEIR  PREPARATION  AND 

ADMINISTRATION.  Seventh  edition,  with  extensive  Additions.  In  one  very  large  octavo 
volume,  leather,  of  770  pages.    $3  75. 

Another  edition  of  the  "  New  Remedies"  having  been  called  for,  the  author  has  endeavored  to 
add  everything  of  moment  that  has  appeared  since  the  publication  of  the  last  edition. 

The  articles  treated  of  in  the  former  editions  will  be  found  to  have  undergone  considerable  ex- 
pansion in  this,  in  order  that  the  author  might  be  enabled  to  introduce,  as  lar  as  practicable,  the 
results  of  the  subsequent  experience  of  others,  as  well  as  of  his  own  observation  and  reilection  ; 
and  to  make  the  work  still  more  deserving  of  the  extended  circulation  with  which  the  preceding 
editions  ha%'e  been  favored  by  the  profession.  By  an  enlargement  of  the  page,  the  numerous  addi- 
tions have  been  incorporated  without  greatly  increasing  the  bulk  of  the  volume. — Preface. 


One  of  the  most  u8eful.of  the  author's  works.— 
Southern  Medical  and  Surgical  Journal. 

Tills  elaborate  and  useful  volume  should  be 
found  in  every  medical  library,  for  as  a  book  of  re- 
ference, for  physicians,  it  is  unsurpassed  by  any 
other  work  in  existence,  and  the  double  index  for 
diseases  and  for  remedies,  will  be  found  greatly  to 


The  great  learning  of  the  author,  and  his  remark- 
able industry  in  pushing  his  researches  into  every 
source  wlience  informatiim  is  derivable, have  enabled 
him  to  tlirow  together  an  extensive  mass  of  facts 
and  statements,  accompanied  by  full  reference  to 
authorities;  which  last  feature  renders  the  work 
practically  valuable  to  investigators  who  desire  tf 


enhance  its  value.— A'ew  York  Med.  Gazette.  examine  the  original  papers.— r/ie  American  Journal 

of  Pharmacy. 


ELLIS  (BENJAMIN),  M.D. 
THE   MEDICAL  FORMULARY :   being  a  Collection  of  Prescriptions,  derived 

from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America  and  Europe. 
Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.  To  which  is  added 
an  Appendix,  on  the  Endermic  use  of  Medicines,  and  on  the  use  of  Ether  and  Chloroform.  The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Observations.  Tenth  edition, 
revised  and  much  extended  by  Robert  P.  Tho.mas,  M.  D.,  Professor  ol  Materia  Medica  in  the 
Philadelphia  College  of  Pharmacy.    In  one  neat  octavo  volume,  extra  cloth,  of  296  pages.    $1  75. 


BLANCHARD    &   LEA'S    MEDICAL 


ERICHSEN    (JOHN), 

Professor  of  i^urstery  in  University  College,  London,  4c. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Suhgical 

Inji-riks,  IJisEASES.  AM>  OPERATIONS.    New  and  improved  American,  from  the  second  enlarged 

and  carelullv  revised  London  t-dilion.     Illustrated  with  over  four  hundred  engravings  on  wood. 

In  one  large  and   handsome  ootavo  volume,  of  one  thousand  closely  printed  pages,  leather, 

raised  bands.     S4  50.     (Just  Issued.) 

The  very  di-iingnished  favor  with  which  this  work  has  been  received  on  both  sides  of  the  Atlan- 
tic has  Biirnulated  tlie  author  to  render  it  even  more  worthy  of  the  position  which  it  has  so  rapidly 
attained  as  a  standard  authority.  Every  portion  has  been  carefully  revised,  numerous  additions 
have  been  made,  and  the  most  watchful  care  has  been  exercised  to  render  it  a  complete  exponent 
of  the  most  advanced  condition  of  surgical  science.  In  this  manner  the  work  has  been  enlarged  by 
about  a  hundred  pages,  while  the  series  of  engravings  has  been  increased  by  more  than  a  hundred, 
rendering  it  one  of  the  most  thoroughly  illustrated  volumes  before  the  profession.  The  additions  of 
tlie  author  liaviiig  rendered  unneces>ary  most  of  the  notes  of  the  former  American  editor,  but  little 
has  been  added  in  this  coinitry ;  some  few  notes  and  occasional  illustrations  have,  however,  been 
introduced  to  elucidate  American  modes  of  practice. 

It  Is,  in  our  liumble  judgment,  decidedly  the  best    step  of  the  operation,  and  not  desertine  him  until  the 
book  of  the  kind  \n  the  Kn^lish  language.    Strange    final  issue  of  the  case  is  decided. — Sethofcope. 
that  just  such  books  are  noiopener  produced  by  pub-  |      Embracing,  as  will  be  perceived,  the  whole  snrgi- 


lic  leacherf  of  surgery  in  lliis  country  and  Great 
Britain  Indeed,  it  is  a  matter  of  great  astonishment, 
but  no  less  true  than  a-^loMishing.  that  of  the  many 
workson  surgery  republished  in  this  country  wiiliin 
the  last  fifteen  or  twenty  years  as  text-books  for 
medical  students,  ihi' is  the  only  one  that  even  ap- 
proximates (o  the  fulfilment  of  the  peculiar  wants  of 
youngmen  jusi  ciUering  upon  the  study  of  this  branch 
of  the  profession. —  WaUrnJoxtr  .of  Med.  an<l  Surgery. 

Its  value  is  greatly  enhanced  by  a  very  copious 


cal  domain,  and  each  division  of  itself  almost  com- 
plete and  perfect,  each  chapter  full  and  explicit,  each 
subject  faithfully  exhibited,  we  can  only  express  out 
esiimaie  of  it  in  the  aggregate.  We  consider  it  an 
excellent  contribution  to  surgery,  as  probably  the 
bes!  single  volume  now  extant  on  the  subject,  and 
with  great  pleasure  we  add  it  to  our  lexi-books. — 
Nashville  Journal  of  Medicine  and  Surgery. 

Prof.  Erichsen's  work,  for  its  size,  has  not  been 
surpassed;  his  nine  hundred  and  eight  page.s,  pro- 
well-arransied  nidex.  We  regard  tliis  as  one  of  the  [  fu«ely  illustrated,  are  rich  in  physiological,  patholo* 
most  valuable  contributions  to  modern  surgery.  To  gical.  and  operative  suggestions,  doctrines,  details, 
one  entering  his  novitiate  of  practice,  we  re-jard  it  '■  and  processes;  and  will  prove  a  reliable  resource 
the  most  serviceable  guide  which  he  can  consult.  He  '  for  information,  both  lo  physician  and  surgeon,  in  the 
will  find  a  tulnessof  detail  leadinghiin  through  every  '  hour  of  peril.— JV.  0.  Med.  and  Surg.  Journal. 


FLINT  (AUSTIN),  M.  D., 

Professor  of  the  Theory  and  Practice  of  .Medicine  in  the  University  of  I^nisville,  &c. 

PHYSICAL  EXPLORATION  AND  DIAGNOSIS  OF  DISEASES  AFFECT- 
ING THE  RESPIK.\TORY  OKGANS.  In  one  large  and  handsome  octavo  volume,  extra 
cloth,  63*3  pages.     $3  00. 

We  reeard  it,  in  point  both  of  arrangement  and  of  |  A  work  of  original  observation  of  the  highest  merit, 
the  marked  abilitv  of  its  treatment  of  the  subjects.  We  recommend  the  treatise  to  every  one  who  wishes 
as  destined  to  take  the  first  rank  in  works  of  this  to  become  a  correct  auscultator.  Based  to  a  very 
class  So  far  as  our  information  extends,  it  has  at  |  large  extent  Hp(m  cases  numerically  examined,  it 
present  no  equal.  To  the  practitioner,  as  well  as  carries  the  evidence  of  careful  study  and  discrimina- 
the  student,  it  will  be  invaluable  in  clearing  up  the  tion  ui.on  every  pau'e.  It  does  credit  to  the  author, 
diagnosis  of  doiibtl'ul  eases,  and  in  shedding  light  and,  through  him,  to  the  profession  in  this  country, 
upon  difficult  phenomena. — Buffalo  Med.  Journal.    I  It  is,  what  we  cnnnot  call  every  book  up(m  auscui- 

I  tation,  a  readable  book. —  Am.  Jour.  Med.  Sciences. 

BY  THE  SAME  AUTHOR.      (Now  Keatiy.) 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOsis,  PATHOLOGY,  AND 

TREATMENT  OF  DISEASES  OF  THE  HEART.     Li  one  neal  octavo  volume,  of  about 

000  pages,  extra  cloth.     §2  75. 

We  do  no*  know  that  Dr.  Flint  has  written  any-  |  diseases  of  the  chest.  We  have  adopted  his  work 
thing  which  is  not  first  rate;  but  this,  his  latest  con-  .upon  the  heart  as  a  text-book,  believing  it  to  be 
tribiition  to  medical  literature,  in  our  opinion,  sur-     more  valu.ible  I'or  that  purpose  than  »ny  work  of  the 


passes  all  the  others.  The  work  is  most  comprehen' 
81  ve  in  Its  pcope,and  mcst  sound  in  the  views  it  enun- 
ciatts.  The  descriptions  are  clear  and  methodical; 
the  slatemcnts  are  substantiated  by  facfs,  and  are 
made  with  such  simplicity  and  sincerity,  that  with- 
out them  they  would  carry  conviction.  The  style  jhe  "nrost'varui.bie'prac'ticai  work  of  it's  kind!— iv"  6! 
18  admirably  clear,  direct,  and  tree  from  dryness      Med.  Aews   Nov.  1S59. 


kind  that  has  yet  appeared. — Nashville  Med.Journ., 
Dec.  lSo9. 

With  more  than  pleasure  do  Are  hail  the  advent  of 
this  work,  for  it  fills  a  wide  gap  on  the  list  i  f  text- 
books for  our  schools,  ami  is,  tor  the  practitioner, 


With  Dr.  Walslie's  excellent  treatise  before  us,  we 
have  no  hesitation  in  saying  that  Dr.  Flint's  book  is 
the  best  work  on  the  heart  in  the  English  language. 
— Boston  Mfd.  and  Surg.  Journal,  Dec.  15,  l,~o9. 

We  have  thus  endeavored  to  present  our  readers 
with  a  fair  analysis  of  tins  remarkable  work.     Pre 


In  regard  to  the  merits  of  the  work,  we  have  no 
hesitation  in  pronouncing  it  full,  accurate,  and  ju- 
dicious. Considering  the  pres-nt  state  of  science, 
such  a  work  was  much  needed.  It  shniiM  lie  in  the 
hunils  of  every  practitioner. — Chicago  Med .  Journal , 


ferring  toeinploy  the  very  wordsofthedistinguished  i  -April,  KhO. 
aull'.or,  wherever  It  was  possible,  we  have  essayed  '  But  these  are  very  trivial  spots,  and  in  no  wise 
to  condense  into  the  briefest  spaeea  genenil  view  of  '  prevent  us  from  declaring  our  most  hearty  approval 
Ins  obscrviitlons  and  suggestions,  and  to  direct  the  ,  of  the  author's  ability,  industry,  and  conscientious- 
attention  of  our  brethren  to  the  abounding  stores  of  \  nesi.—  Di(blin  Quarterly  Journal  of  Med.  Sciences, 
valuable  mutter  hcrecollccted and  arraiiged  for  their  '  Feb.  l?li(). 
uaeand  in-truetion.    No  medical  library  will  here    i      He  has  labored  on  wi'h  the  same  indu.'^try  and  care, 


after  be  considered  complete  without  this  vcduine; 
and  we  tnis'  It  will  promptly  find  its  way  into  the 
hands  nf  every  Amciican  student  and  physician. — 
iV.  Am.  Med.  Chir.  Review,  Jan   ISOO. 
This  last  work  of  Prof.  Flint  will  add  much  to 


and  his  place  among  the  /!r,<t  authors  of  our  country 
is  becoming  fully  esi.-ibliLhed.  To  I  his  end,  the  work 
whose  title  is  given  above,  coniributes  in  no  small 
degree.  Our  spa  e  will  not  admit  of  tn  extended 
analysis,  and  we  will   clogt    this    iirief  no'ice  by 


his  previous  well-enrned  celebrity,  as  a  writer  of  !  commending  it  without  reserve  to  every  class  of 
great  forccand  beauty,  and,  with  his  previous  work,  1  readers  in  the  profession. — Peninsular  Med.  Journ., 
places  him  at  the  head  of  American  writers  upon     Feb.  l!?CO. 


AND    SCIENTIFIC    PUBLICATIONS. 


15 


FOWNES  (GEORGE),  PH.  D.,  «tc. 
A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and  Practical. 

From  the  seventh  revi>eil  and  correcteii  London  edition.     With  one  himdred  and  ninety-seven 

illustrations.     Edited  !)v  Robert  Bridges,  M.  D.     In  one  large  royal  12mo.  volnme,  of  (300 

pages.     In  leather,  $1  65;  extra  cloth,  $1  50.     {Jiixt  Isaned.) 

The  death  of  the  author  liavnig;  placed  the  editorial  care  of"  this  work  in  the  practised  hands  ol 
Drs.  Bence  Jones  and  A.  \V.  Hudrnan,  everything  ha<  l)een  done  in  its  revision  which  experience 
could  suggest  to  keep  it  on  a  level  with  the  rapid  advance  of  chemical  science.  The  additions 
requisite  to  thi*  purpose  have  Heces>ilated  an  enlargement  of  the  page,  notwithstanding  which  the 
work  has  been  increased  by  about  fifty  pages.  At  the  same  time  every  care  has  been  used  to 
maintain  its  distinctive  character  as  a  condensed  manual  for  the  student,  divested  of  all  unnecessary 
detail  or  mere  theoretical  speculation.  The  additions  have,  of  course,  been  mainly  in  the  depart- 
ment of  Organic  Chemistry,  which  has  made  such  rapid  progress  within  the  last  few  years,  but 
yet  equal  attention  has  been  bestowed  on  the  other  branches  of  the  subject — Chemical  Physics  and 
inorganic  Chemistry — to  present  all  investigations  and  discoveries  of  importance,  and  to  keep  up 
the  reputation  of  the  volume  as  a  complete  manual  of  the  whole  science,  admirably  adapted  for  the 
learner.  By  the  use  of  a  small  but  exceedingly  clear  type  the  matter  of  a  large  octavo  is  compressed 
within  the  convenient  and  portable  limits  of  a  moderate  sized  duodecimo,  and  at  the  very  low  price 
affixed.  It  is  otVered  as  one  of  the  cheapest  volumes  before  the  profession. 

Dr.  Fownrs'  excellent  work  lias  lieen  universally 
recopnized  everywhere  in  Ills  own  and  this  country, 
as  the  best  elemenlHry  treatise  on  chemistry  in  the 


English  tongue,  and  is  very  generiillv  ailnptcd,  we 
believe,  as  the  standard  text  book  in  all  <  urcolk'ses, 
both  literary  nnd  Ecientific. — Charleston  Med  Journ. 
anc   Itvieic,  i*ept.  1859. 

A  standard  m.inual,  which  has  long  enjoyed  the 
reputatimi  of  emtiodying  much  knowlediroin  a  small 
space.  The  author  hasachieved  the  diflicult  task  of 
eondensation  with  masterly  taot.  His  hook  is  con- 
cise without  being  dry,  and  brief  without  being  too 
dogmatical  or  general. —  Virginia  Med.  and  Surgical 
Journal. 


The  work  of  Ur.  Fownes  has  long  been  before 
the  public,  and  its  merits  have  been  I'uUy  appreci- 
ated as  the  best  text-book  on  chemistry  now  in 
existence.  We  do  not,  of  course,  place  it  in  a  rank 
superior  to  the  ,,-orks  of  Brande,  Graham,  Turner, 
Gregory,  or  Gmelin,  but  we  say  that,  as  a  work 
for  stuclents,  it  is  preferable  to  any  of  them. — Lon- 
don Journal  of  Medicine. 

A  work  well  adapted  to  the  wants  of  the  student 
It  is  an  excellent  exposition  of  the  chief  cloctrines 
and  factsof  modernchemistry.  The  size  of  the  work, 
and  still  more  the  condensed  yet  perspicuous  style 
in  which  it  is  written,  absolve  it  from  the  charges 
very  properly  ur^ed  against  most  manuals  termed 
popular. — Edinburgh  Journal  of  Medical  Science. 


FISKE    FUND    PRIZE    ESSAYS  —THE    EF- 
FECTS OF  CLI.MATE   ON   TaiJERCULOUS 
DISEASE.    I!v  EnwiN  Lee,  M.  R.  C  S  ,  London, 
and  THK  INFIATENCE  OF  PREGNANCY  ON  I 
THE  DEVELOl'MEIMT  OF  TUBERCLES     By 


Edward  Wabken,  M.  D  ,  of  Edent.on,  N.  C.  To- 
srether  in  one  neat  8vo  vnlume,  extra  cloth.  SI  00. 
FRICK  ON  RENAL  AFFECTIONS;  their  Diag- 
nosis and  Pathology.  With  illustrations.  One 
volume,  royal  ISmo.,  extra  cloth.     75  cents 


FERGUSSON  (WILLIAM),  F.  R.  S., 

Professor  of  Surgery  in  Kind's  Collea;e,  London,  &c. 

A  SYSTEM  OP  PRACTICAL  StlRaERY.     Fourth  American,  from  the  third 

and  enlarged  London  edition.    In  one  large  and  beautifully  printed  octavo  volume,  of  about  700 
pages,  with  393  handsome  illustrations,  leather.     $3  00. 

GRAHAM  (THOMAS),  F.  R.  S. 
THE  ELEMENTS   OF   INORGANIC   CHEMISTRY,  including  the  Applica- 

lions  of  the  Science  in  the  Arts.   New  and  much  enlarged  edition,  by  He.nry  Watts  and  Robert 
Bridgks,  M.  D.     Complete  in  one  large  and  handsome  octavo  voliime,  of  over  SOO  very  large 
pages,  with  two  hundred  and  thirty-two  wood-cuts,  extra  cloth.     $4  00. 
^t*i^  Part  II.,  completing  the  work  from  p.  431  to  end,  with  Index,  Title  Matter,  &c.,  may  be 

had  separate,  cloth  backs  and  paper  sides.     Price  $2  50. 

From  Prof.  E.  N.  Horsford,  Harvard  College.      \  afford  to  be  without  this  edition  of  Prof.  Graham's 
It  has,  in  its  earlier  and  less  perfect  editions,  been     Kleincnts.— Si/r/wian's /ottrnoZ,  March,  1859. 

familiar  to  me,  and  the  excellence  of  its  plan  and       p^„,„  p^„^  ^^^j        g;^^     ^  y.  Free  Academy. 

the  clearness  and  completeness  of  its  discussions,        ™,  "  » 

have  long  been  my  admiration.  .   The  work  is  an  admirable  one  in  all  respects, and 

its  republication  here  cannot  fiil  to  exert  a  positive 
No  reader  of  English  works  on  this  science  can    influence  upon  theprogressof science  in  thiscountry. 

GRIFFITH  (ROBERT  E.),  M.  D.,  &c. 
A  UNIVERSAL  FORMULARY,  containing  the  methods  of  Preparing  and  Ad- 
ministering Ollicinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceu. 
lists.  Seco.nd  Edition,  thoroughly  revised,  with  numerous  additions',  by  Robert  P.  Tho.mas, 
M.  D.,  Profe>sor  of  Materia  .Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large  and 
handsome  octavo  volume,  extra  cloth,  of  er^O  pages,  double  columns.  S3  00;  or  in  sheep,  $3  25. 
It  was  a  work  requiring  much  per.severaiice,  and       This  is  a  work  of  six  hundred  and  fifty-one  pages 


when  published  wa.«  looked  upon  as  by  far  the  best 
work  of  its  kind  that  had  issued  from  the  American 
pres.s.  Prof  Tlioma=  has  certainly  "improved."  as 
well  as  added  lolliis  Formulary,  and  has  rendered  ii 
additionally  deserving  of  the  confidence  of  pharma- 
ceutists and  physicians. — Am.  Journal  of  Pharmacy. 
We  are  happy  to  announce  a  new  and  improved 
edition  of  this,  one  of  the  most  valuable  and  useful 
works  that  have  e-naiiated  from  an   American  pen. 


embracing  all  on  the  su!>jeci  of  preparing  and  admi- 
iilslerine  medicines  that  can  he  desired  by  the  physi- 
cian ana  pharmaceutist. —  Wesiern  Lancet. 

The  amouiilof  useful, every-day  mauer.for  a  prac- 
ticiiie;  physician,  is  really  immense.— £ox/on  Med. 
and  Surg.  Journal. 

This  edition  has  been  etreatU  improved  by  the  re- 
vision and  ample  a<ldnioiis  of  Dr  Thomas,  and  is 
now,  we  believe,  one  of  the  mosi  complete  works 


It  would  do  credit  to  any  country,  and  will  he  found    "f"'  wi.wi     ,  Vn,:  i„n„  YL       ^\       .u.  .,mc,c  wur»» 
„f  H„ilv  „.,,-„l,„...  ,„  nr,.e.;Mnnnr«  „,■  m..,ll,.;„e.  ,.  „    "'  '."  '"'"'  '"  "">  'inguage.    The  additions  amount 


of  daily  u-efuliiess  to  practitioners  of  medicine;  it  is 


to  about  seventy  pairc«,  and  nc  effort  ha-;  been  spared 


euer  adapted  lo  iheir  purposes    hai,  ihe  dispensaio-  .  ,„  i,,^.,,,,,^  j,,  ,^Vm  all  the  recent   improvemen 


Ties. — Southern  Mtd.  and  Surg.  Journal. 


work  of  this  kind  appears  to  u«  indispensable  to  the 


Itis  one  of  the  most  useful  books  a  country  practl- 1  physician,  and  ihere  is  none  we  can  more  cordially 
ioner  can  possibly  have.— Jtferfi'cni  CAro/iic.'*.  '  recommend.— iV.  Y.  Journal  of  Medicine.  ^ 


recommend.— iV.  Y.  Journal  of  Medicine. 


Iti  BLANCHARD   &    LEA'S   MEDICAL 


GROSS  (SAMUEL  D.),   M.  D., 
Professor  of  Surgery  lu  the  Jeircrson  Medical  College  of  Philadelphia,  &c. 
Just  Issued. 
A  SYSTEM  OF  SURGERY :  Pathological,  Diagnostic,  Therapeutic,  and  Opera- 
tive.    Illusiraled  by  Nine  HuNnuED  and  Thirtv-six  Engravings.     In  two  larg-e  and  beautifully 
•    printed  octavo  volume-,  of aearl J' twenty-four  hundred  pages;  strongly  bound  in  leather,  with 
rai»ed  bands.     I'rice  $12. 

From  the  Author's  Preface. 

"  The  object  of  this  work  is  to  furnish  a  syslematic  and  comprehensive  treatise  on  the  science  and 
practice  of  siirpery,  considered  in  the  broadest  sense;  one  that  shall  serve  the  practitioner  as  a 
faithful  and  availiibie  guide  in  his  daily  routine  of  duty.  It  has  been  too  much  the  custom  of  mod- 
ern writers  on  this  department  o(  the  healing  art  to  omit  certain  topics  altogether,  and  to  speak  ol 
others  at  undue  length,  evidently  assuming  that  their  readers  could  readily  supply  the  deficiencies 
Irom  other  sources,  or  that  what  has  been  thus  slighted  is  of  no  particular  practical  value.  My  aim 
has  been  to  eml)race  the  whole  domain  of  surgery,  and  to  allot  to  every  subject  its  legitimate  claim 
to  notice  in  the  great  family  of  external  diseases  and  accidents.  How  far  this  object  has  been  accom- 
plished, it  is  not  for  me  to  determine.  It  may  safely  be  utiirmed,  however,  that  there  is  no  topic, 
properly  appertaining  to  surgery,  that  will  not  be  found  to  be  discussed,  to  a  greater  or  less  extent, 
in  these  volmnes.  If  n  larger  space  than  is  customary  has  been  devoted  to  the  consideration  of 
mllammalion  and  its  results,  or  the  great  princijiles  of  surgery,  it  is  because  of  the  conviction, 
grountled  upon  long  and  close  observation,  that  there  are  no  subjects  so  little  understood  by  the 
general  practitioner.  Special  attention  has  also  been  bestowed  upon  the  discrimination  of  diseases; 
and  an  elaborate  chapter  has  been  introduced  on  general  diagnosis." 

That  these  intentions  have  been  carried  out  in  the  fullest  and  most  elaborate  manner  is  sufficiently 
shown  by  the  great  extent  of  the  work,  and  the  length  of  time  during  which  the  author  has  been 
concentrating  on  the  task  his  studies  and  his  experience,  guided  by  the  knowledge  which  twenty 
years  of  lecturing  on  surgical  topics  have  given  him  of  the  wants  of  the  profession. 

Of  Dr.  GroBs's  treatise  on  Surgery  we  can  say  1  At  present,  however,  our  object  is  not  to  review 
no  more  than  that  it  is  the  most  elaborate  and  com-  the  work  (this  we  purpose  doing  hereafter),  but 
pletf  work  on  this  branch  of  the  I.eiiliiig  art  which  simply  to  announce  its  appearance,  that  m  the 
has  ever  been  published  in  any  country.  A  sys-  j  meantime  our  readers  may  procure  aud  examine  it 
tcmatic  work,  it  admits  of  no  analytical  review;  i  for  themselves.  But  even  this  much  we  cannot  do 
but,  did  our  space  pi-riiut,  we  should  gladly  give  j  without  expressing  the  opinion  tliat,  in  putting  forth 
gome  extracts  from  it,  to  enable  our  readers  to  judge  thpse  two  volumes.  Dr.  Gross  has  reared  for  hira- 
of  the  c'assiciil  style  of  the  author,  and  the  exhaust- I  self  a  lasting  monument  to  his  skill  as  a  surgeon, 
ing  way  in  which  each  subject  is  trented. — Dublin  '  and  to  his  industry  and  learning  as  an  author. — St. 
Quarterly  Journal  of  Med.  Science,  Nov.  1859.  I  Louis  Med.  and  Surg.  Journal,  Nov.  1S59. 

The  work  is  so  superior  to  its  predecessors  in  j  "With  pleasure  we  record  the  completion  of  this 
matter  and  extent,  as  well  as  in  illustrations  and  long-anticipated  work.  The  reputation  which  the 
style  of  publication,  that  we  can  honestly  recom-  autlior  has  for  mauv  vears  sustained,  both  as  a  sur- 
mend  It  as  the  best  work  of  the  kind  to  be  taken  |  pe„n  „nj  „g  ^  writerj  had  prepared  us  to  expect  a 
home  by  the  young  practitioner.—^;/!.  Med.  Joum.,  |  treatise  of  great  excellence  aud  originality;  but  we 
Jan.  ISCO.  confess  we  were  by  no  means  prepared  tor  the  work 

The  treatise  of  Prof.  Gross  is  not,  therefore,  a  I  which  is  before  us — the  most  complete  treatiseupon 
mere  te.xl-liook  for  undergraduates,  but  a  systema-  surgery  ever  published,  either  in  this  or  any  othtr 
tic  record  of  more  than  thirty  years'  experience,  I  country,  and  we  might,  perhaps,  safely  say,  the 
reading,  and  retlection  by  a  man  of  observation,  !  most  original.  There  is  no  subject  belonging  pro- 
sound  judgment,  and  lare  practical  tact,  and  as  such  j  perly  to  surgery  which  has  not  received  from  the 
deserves  to  take  rank  with  the  renowned  produc-  I  authoia  due  share  of  attention.  Dr.  Grots  has  sup- 
lions  of  a  similar  character,  by  Vidal  and  Boycr,  of  [  plied  a  want  in  surgical  literature  which  has  long 
France,  or  those  of  Ohelius,  Blasius,  and  Langen-  been  felt  by  practitioners;  he  has  furnished  us  with 
been,  of  (jerinany.     Hence,  we  do  not  hesitate  to    a  complete  practical  treatise  upon  sargery  in  all  its 


departments.  As  .■Xmericins,  we  are  proud  of  the 
achievement;  as  surgeons,  we  are  most  sincerely 
thankful  to  him  for  his  extraord  narv  labors  in  our 
behalf— iV.  Y.  Monthly  Review  and  Buffalo  Med. 
Journal, Oct.  1S50. 


express  the  opinion  that  it  will  speedily  take  the 
same  elev:ited  position  in  regard  to  surgery  that  has 
been  given  by  common  consent  to  the  masterly  work 
of  Pereira  in  Materia  Medica,  or  to  Todd  and  Bow- 
man in  Physiology. — y.  O.  Med.amd  Swg.  Journal, 
Jan.  IbGO.  | 

BY  THE  SAMS  AUTHOR. 

ELEMENTS  OF  PATHOLOGICAL  ANATOMY.     Third  edition,  thoroughly 

revi>ed  mid  greatly  improved.     In  one  large  and  very  handsome  octavo  volume,  with  about  three 
hundred  and  lif'ty  U-autiful  illustrations,  of  which  a  large  numlier  are  from  original  drawings. 
I'rice  in  extra  cloth,  $J  75;  leather,  rai-sed  bands,  S!i  25.     (Lately  Piihli.^lied.) 
The  very  rapid  advances  in  the  Science  of  Pathological  Anatomy  during  the  last  few  years  have 
rendered  essential  a  thorough  modification  of  this  work,  with  a  view  of  making  it  a  correct  expo- 
nent of  the  present  state  of  the  subject.     The  very  careful  manner  in  which  this  task  has  been 
executed,  and  the  aiuount  of  alteration  which  it  has  undergone,  have  enabled  the  author  to  say  thai 
"  wilh  the  iiiniiy  changes  and  iiTiprovements  now  introduced,  the  work  may  be  regarded  almost  as 
a  new  treatise,"  while  the  etiorts  of  the  atithor  have  l)een  seconded  as  regards  the  mechanical 
execution  of  the  volume,  rendering  it  one  of  the  handsomest  productions  o(  the  American  press. 

We  most  sincerely  congratulate  the  author  on  the  ,  We  have  been  favorably  impressed  with  the  gene- 
■uccessfiil  manner  in  w.'iich  he  has  accomplished  his  '  ral  manner  in  which  Dr.  Gross  has  executed  his  task 
propnied  object.  His  book  is  most  admirably  cal-  ,  of  affording  a  comprehensive  digest  of  the  present 
Rulatrd  to  fill  up  a  blank  which  has  long  been  fi;lt  to  [  state  of  the  literature  of  Pathological  Anatomy ,  and 
exist  in  IliiH  drp.-irtment  of  medical  literature,  and  have  much  pleasure  in  recommending  his  work  to 
as  such  must  become  very  widely  circulatetl  amongst  our  readers,  as  we  believe  one  well  deserving  of 
all  clnHsrR  of  the  profession. —  Dublin  <^iiar«er/y  ,  diligent  perusal  and  careful  study. — Montreal  Med. 
Joum.  of  Med.  Science,  Nov.  1857.  j  Ckron.,  Sept.  1657. 

BY  THK  SAMK  AUTHOR. 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE  AIR-PAS- 

SAGE^.     Ill  one  handsome  octavo  volume,  extra  cloth,  with  illustrations,    pp.  4t)8.    $2  75. 


AND    SCIENTIFIC   PUBLICATIONS. 


17 


GROSS  (SAMUEL   D.),   M.  D., 
Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelpliia,  &c. 

A  PRACTICAL    TREATISE   ON   THE    DISEASES,    INJURIES,  AND 

MALFORMATIONS  OF  THE  UKINAKY  BLADDER,  THE  PROSTATE  GLAND,  AND 
THE  URETHRA.  Second  Edition,  revised  and  much  enlarg-ed,  with  one  hundred  and  eighty- 
four  illustrations.  In  one  large  and  very  handsome  octavo  volume,  of  over  nine  hundred  pages. 
In  leather,  raised  bands,  $5  25;  extra  cloth,  $4  75. 

Philos'ipliio.Tl  in  its  design,  metlKidiciil  in  its  ar-  i  agree  with  us,  that  there  is  no  work  in  the  English 
rangement,  simple  and  sound  in  its  practical  details,    language  which  can  make  any  just  pretensions  to 
it  may  in  truth  he  said  to  leave  scarcely  anything  to    be  its  equal. — N.  Y.  Journal  of  Medicine . 
be  desired  on  so  important  a  subject.— Uosron  Med.  .      a  volume  replete  with  truths  and  principles  of  the 

utmost  value  in  the  investigation  of  these  diseases.    - 


and  SuTg  Journal. 

Whoever  will  peruse  the  vast  amount  of  valuable 
practical  intormation  it  contains,  will,  we  think, 


American  MedicalJoumal . 


GRAY  (HENRY),   F.  R.  S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London,  &c. 

ANATOMY,  DESCRIPTIVE  AND   SURGICAL.      The  Drawings  by  H.  V. 

Carter,  M.  D.,  late  Demonstrator  on  Anatomy  at  St.  George's  Hospital ;  the  Dissections  jointly 
by  the  Author  and  Dr.  Carter.  In  one  magnificent  imperial  octavo  volume,  of  nearly  800 
pages,  with  363  large  and  elaborate  engravings  on  wood.  Price  in  extra  cloth,  $6  25;  leather 
raised  bands,  $7  00.    (Just  Issued.) 

The  author  has  endeavored  m  this  work  to  cover  a  more  extended  range  of  subjects  than  is 
customary  in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  (or  the  active  practitioner.  The 
ejigravings  form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  purls  printed  on  the  body  of  the  cut,  in  place  of  figures 
of  reference  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series,  which 
will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to  refresh 
the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling  the  details 
of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with  a  thorough 
treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of  essential  use 
to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and  pupil  of  much 
labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

The  work  before  us  is  one  entitled  to  the  highest  1  to  exist  in  this  country.  Mr.  Gray  writes  through- 
praise,  and  we  accordingly  \veleome  it  as  a  valu-  :  out  with  both  branches  of  his  subject  in  view.  His 
able  addition  to  medical  literature.  Intermediate  ^  description  of  each  particular  part  is  followed  by  a 
in  fulness  of  detail  between  the  treatises  of  S  lar  :  notice  of  its  relations  to  tie  parts  with  which  it  is 
pey  and  of  Wilson,  its  characteristic  merit  lies  in  i  connected,  and  this,  too,  sufficiently  ample  for  all 
the  number  and  excellence  of  the  engravings  it  |  the  purposes  of  the  0|>erative  surgeon.  After  de- 
contains.  Most  of  these  are  original,  of  much  j  scribing  tlie  bones  and  muscles,  he  gives  a  concise 
larger  than  ordinary  size,  and  admirably  executed,  statement  of  the  fractures  to  which  the  bones  of 
The  various  parts  are  also  lettered  after  the  plan  the  extremities  are  most  liable,  together  with  the 
adopted  in  Holden's  Osteology.  It  would  be  uiffi-  amount  and  direction  of  the  displacement  to  which 
cult  to  over-estimate  the  advantages  offered  by  this  the  fragments  are  subjected  by  muscular  action, 
mode  of  piciorial  illusiratiun.  Bones,  ligaments.  The  section  on  arteries  is  remarkably  full  and  ac- 
muscles,  bloodvessels,  and  nerves  are  each  in  turn  ,  curate.  Not  only  is  the  surgical  anatomy  given  to 
figured,  and  marked  with  their  appropriate  names;  evjry  important  vessel,  with  directions  for  its  liga- 
thus  enabling  the  student  to  c(  mpreliend,ata  glance,  tion,  but  at  the  end  of  the  description  of  each  arte- 
what  would  otherwise  often  be  ignored,  or  at  any  rial  trunk  we  have  a  useful  summary  of  the  irregu- 
rate,  acquired  only  by  prolonged  and  irksome  ap-  larities  which  may  occur  in  its  origin,  course,  and 
plication.  In  conclusion,  we  heartily  commend  the  termination. — N.  A.  Med.  Chir.  Review,  Mar.  1559. 
work  of  Mr.  Gray  to  the  attention  of  the  medical 


profession,  iVeling  certain  tliat  it  should  be  regarded 
as  one  of  the  most  valuable  contributions  ever  made 
to  educational  literature. — A'.  Y.  Monthly  Review. 
Dec.  1859. 

In  this  view,  we  regard  the  work  of  Mr.  Gray  as 
far  better  adapted  to  the  wants  of  the  professiim, 
and  especially  of  the  student,  than  any  treatise  on 
anatomy  yet  published  in  this  country.  It  is  destined. 
we  believe,  to  supersede  \\[  others,  both  as  a  manual 
of  dissections,  and  a  standard  of  reference  to  the 
student  of  general  or  relative  anatomy.  —  N.  Y. 
Journal  of  Medicine,  Nov.  1859. 

This  is  by  all  comparison  the  most  excellent  work 
on  Anatomy  extnnt.  It  is  just  the  thin^  that  has 
bc«n  long  desired  by  the  profession.  With  such  a 
euide  as  this,  the  student  of  anatomy,  the  practi- 
tioner of  medicine,  and  the  surgical  devotee  have 
all  a  newer,  deirer,  and  more  radiant  light  thrown 
npon  the  intricacies  and  mysteries  of  this  wonder- 
ful tcience,  and  are  thus  enabled  to  accomplisli  re- 
sults which  hitherto  seemed  poscible  only  to  the 
■pecialist.    The  plates,  which  are  copied  Crom  re- 


Mr.  Gray's  book,  in  excellency  of  arrangement 
and  comnleteness  of  execution,  e.xcteds  any  work 
on  anatomy  hitherto  published  in  the  English  lan- 
guage, affording  a  complete  view  of  the  structure  of 
the  tiuman  body,  with  especial  reference  to  practical 
surgery.  Thusthe  volume  constitutesa  perfectbook 
of  reference  for  the  practitioner,  dem.inding  a  place 
in  even  the  most  limited  library  of  the  physician  or 
surgeon,  and  a  work  of  nee  ssity  for  the  student  to 
fix  in  his  mind  what  he  has  learneil  by  the  dissecting 
knife  from  the  book  of  nature. — The  Dublin  Quar- 
terly Journal  of  Med.  Sciences,  Nov.  1858. 

In  our  judgment,  the  mode  of  illustration  adopted 
in  the  present  volume  cannot  but  present  many  ad- 
vantages to  the  studentof  anatomy.  To  the  zealous 
disciple  of  Vesalius,  eiirnestly  desirous  of  real  im- 
provement, the  book  will  certainly  be  of  immense 
value;  but,  at  the  same  time,  we  must  also  confess 
that  to  those  simply  desirous  of  "cramming"  it 
will  be  an  undoubted  eodsend.  The  peculiar  value 
of  Mr.  Gray's  mode  of  illustration  is  nowhere  more 
markedly  evident  than  in  the  chapter  on  osteology, 
and  especially  in  those  portions  which  treat  of  the 


cent  dissections,  are  so  well  executed,  that  the  most    bones  of  the  head  and  of  th-ir  development.    The 
superficial  observer  cannot  fail  to  perceive  the  posi      gt^jy  „f  j|,pgg  p.^^jg  jg  t,,ug  „„^,|g  „„g  „f  comparative 

ense,  if  notof  positive  pleasure  :  and  those  bugbears 


tions,  relations,  and  distinctive  features  of  the  vari- 
ous parts,  and  to  tnkf  in  more  of  anatomy  at  a  glance, 
than  by  many  long  hours  of  diligent  study  over  the 
most  erudite  treatise,  or,  perhaps,  at  the  dissecting 
table  itself. — Med.Journ.  of  N.  Carolina,  Oct.  1^59. 
For  thi.s  truly  admirable  work  the  profession  is 
indebted  to  the  distinguished  author  of  "Gray  on 
the  Spleen."    The  vacancy  it  fills  has  been  long  felt 


if  the  student,  the  leinjioral  and  sphenoid  bones,  are 
shorn  of  half  their  terrors.  It  is,  in  our  estimation, 
an  admirable  and  complete  text-book  for  the  student, 
and  a  useful  work  of  reference  for  the  practitioner; 
its  pictorial  character  forming  a  novel  element,  to 
which  we  have  already  sufficiently  alluded. — Am. 
Journ.  Med.  Sci.,  July,  1859. 


18 


BLANUHAKD    &    LEA'S    MEDICAL 


GIBSO.V'S  INSTITL'TKS  AND  PRACTICE  OF  i 
8URGKUV.     Eirhih  rditifin,  improveil  niid  hI- 
tertd.    With  thirty-four  platrs.    In  two  handsome 
(Hrtavo   volumti,  containtnir  iibuut   1,000   pages, 
leather,  raised  band  1.     SO  SO. 

GARDNKR'S  MKUICAL  CHKMISTRY,  for  the 
use  of  (Students  and  the  Profi'Rsion.  In  one  royal 
I2ino.  vol.,  clotli,  pp.  :J90,  with   woodcuts.     91. 

UI.fUE'S  ATL.\.S  or  PATHOi.OGICAL  HIS- 
TOLOGY.     Trar.8lutid,  wilh   Notes  and  Addi- 


tions, by  Joseph  Leidy,  M.  D.  In  one  volume, 
very  lar^e  imperial  quarto,  extra  cloih,  wi'i320 
cupper- plate  hgures,  plain  and  eolorcd,    S5  00. 

HUGHES'  INTRODUCTION  TO  THE  PRAC- 
TICE OP  AUSCL'LTAI'ION  A.M/  OTHER 
.MODE!*  OF  PHYSICAL  DIAGNOSIS  IN  DIS- 
EASES  OF  THE  LUNGS  AND  HEART.  Se- 
cond edition  1  vol.  royal  lamo.,  ex.  cloth,  pp. 
304.    81  00. 


HAMILTON  (FRANK    H.),   M.   D., 

ProiVggor  of  Surpcry  in  the  Uaivergity  of  BulTalo,  &c. 

A  PRACTICAL  TREATISE  ON  FRACTURES  AND  DISLOCATIONS. 


In 


one  lurjre  and  hQiidsome  ocluvo  volume,  of  over  700  pages,  with  289  illuslralioiisi.    SI  25.    (Nou> 

litady,  January,  ISOO.) 

This  is  n  valuable  contribution  to  the  surgery  of  '  illustrated,  which  will  be  a  desideratum  for  those 
most  important  atTectitms.and  is  the  more  welcome,  practitioners  who  cannot  conveniently  see  the  mo- 
inasmuch  as  at  tlie  prcstnt  time  we  do  not  pi>8gcs»  dels  applied. — A'em  Yorlt  Med.  Press,  Feb  4,  1860. 
a  siHRle  complete  treatue  on  Fraciurcs  and  Dislo-  ^y^  rccard  this  work  as  an  honor  not  <mly  to  its 
cations  in  the  Knijlish  lanftua?e.  It  has  remained  for  „uthor,  but  to  the  profession  of  our  country.  Were 
our  Amen.an  brother  to  produce  a  complete  treatise  ^.g  t„  review  it  thoroushlv,  we  could  not  convey  to 
upon  the  subject,  and  bring  together  in  a  convenient  t,,^  „,ind  „f  ,,,e  reader  more  forcibly  our  hontst 
form  those  alterations  and  improvements  that  have  opinion  expressed  in  the  few  word..— we  think  it  the 
been  made  from  time  to  time  in  the  treatment  of  these     ^^81  1 k  ol  its  kind  extant.     Every  man  interested 


affections.  One  great  and  valuable  feature  in  the 
work  before  us  is  the  fact  that  it  comprises  all  the 
improvemen's  introduced  into  the  practice  of  both 
ICo^lishand  American  surgery,  and  though  far  from 
omitting  mention  of  our  continental  neijjhborR,  the 
author  by  no  means  tncourages  the  notion — but  too 
prevalent  in  some  quarters— that  nothing  is  pood 
unless  imported  from  France  or  Germany.  Tlie 
latter  half  of  the  work  is  devoted  to  the  considera- 
tion of  the  various  dislocations  and  their  appropri- 


in  surgery  will  soon  have  this  work  on  his  desk. 
He  who  does  not,  will  be  the  loser. — Ntw  Orleam 
Medical  l\'ews,  March,  1660. 

Now  that  it  is  before  us,  we  feel  bound  tosay  that 
much  as  was  expected  from  it.  and  onerous  as  was 
tlie  undertaking,  it  has  surpassed  expcctalbm,  and 
achieved  more  than  was  pledged  in  its  behalf;  for 
its  title  does  not  express  in  full  the  rirhress  of  its 
contents.      On  the  whole,  we  are  prouder  of  this 


ate  treatment,  and  its  merit  is  fully  equal  to  that  of  Y^"'"''  ,"'''"  "'"  ""y  which   has  for  years  emanated 

the  preceding  portion.— TAe  London  Lanett, May  5,  ''^""?  ".'^  American  medical  press;  its  sale  will  cer- 

IgflO.                                                                        )        .-     I  tainly  be  very  large  in  this  country,  and  we  antiei- 

,.'.            ,.•!.,,,                .          ,.            ,  pate  Its  eliciting  much  attention  in  Europe. — Nash- 

It  IS  emphatically  the  book  upon  the  subjects  of  ^m^  Medical  Record,  Mar.  l&OO. 

which   It   treats,  and  we  cannot  doubt   that  it  will  „                                                   ,,,,,, 

cmtinue  s>i   to  be  for  an   indefinite  period  of  time  Every  surgeon,   young   and   old,  should   possess 

When  we  say.  however,  that  we  believe  it  will  at  bimtelf  of  it,  and  give  it  a  careful  perusal,  in  d<iing 

oncetakeilsplaceas  the  best  book  f<ir  consultation  ^v''"""  ''«=  W'  ^•^  richly  repaid.— S«.  Louis  Med. 

by  the  practitioner;  and  that  it  will  form  the  most  "'"'  ^"^S-  Journal,  March,  ISGO. 

complete,  available,  and  reliable  guide  in  emergen-  Dr.  Hamilton  is  fortunate  in  having  succeeded  in 

ciesof  every  nature  connected  witli  its  subjects;  and  filling  the  void,  so  long  felt,  with  wiiat  cannot  fail 

also  that  thestu<lentof  surgery  may  imike  it  his  text-  to  be  at  once  accepted  as  a  model  monograph  in  some 

book  wi:h  entire  confidence,  and  with  pleasure  also,  respects,  and  a  work  of  classicil  authority.     We 

from  Its  agreeible  and  easy  style — we  think  our  own  sincerely  congratulate  the  profession  of  the  United 

opinion  innv  be  gathered  as  to  its  value. —  Boston  Stales  on  the  appearance  of  such  a  publication  from 

Medical  and  Surgical  Journal,  March  1,  1860.  one  of  their  number.    We  have  reason  to  be  proud 

The  work  is  concise,  judicious,  and  accurate,  and  "f  'f  ""  «"  original  work,  both  in  a  literary  and  sei- 

adapted  to  the  wants  of  the  student,  practitimer,  entific  point  of  view,  and  to  esteem  it  as  a  valuable 

and  investigator,  lumoruble  to  the  author  and  to  the  Pi'ide  in  a  most  ditlicult  and  important  branch  of 

profession.— CAicn^o  i»f«rf.Journai,  March,  1800.  study  and  practice.     On  every  account,  therefore, 

we  hope  that  it  may  soon  be  widely  known  abroad 

We  venture  to  say  that  this  is  not  alone  the  cmly  as  an  evidence  of  genuine  prcgress  on  this  side  of 

complete  treatise  on  the  subject   in   the  language,  the  Atlantic,  and  further,  that  it  may  be  still  more 

but  the  best  and  mout  practical  we  have  ever  read!  widely  known  at  home  as  an  authoritative  teacher 

The  arrniigenient  is  simple  and  syslematic,  the  die-  from  which  every  one  may  profitably  learn,  and  as 

tion  clear  anil  graphic,  and  the  illustrations  nume-  airi>rding  an  example  of  honest,  well-directed,  and 

rous  and  remarkable  fur  accuracy  of  delineutitm.  uttiring  industry  in  authorship  which  every  surgeon 

The  various  mechanical  appliances  are  faithfully  may  en.ulate.-  Am.  Med.  Journal,  April,  1860. 


HOBLYN  (RICHARD  D.),  M.  D. 
A  DICTIONARY  OF  THE  TERMS   USED  IN  MEDICINE  AND  THE 

COLL.ATliKAL  SCIENCES.     A  new  American  edition.     Revised,  with  numerous  Additions, 

by  Isaac  Hays,  M.  D.,  editor  of  the  "  Aniencnii  Jotinial  olthe  Medical  Sciences."    In  one  large 

royul  r.im<).  volume,  leather,  of  over  OOO  double  columned  pages.     $1  SO. 

To  both  practitioner  and  stu<lentj  we  recommend    use  ;  embracing  every  department  of  medical  science 

this  dictionary  as  being  convenient  in  size,  accurate  '  down  to  the  very  latest  date.— ITt.Wf  rn  Lancet. 

!,"rdinnr"v'.c';n:.'.'l'I!!,'""'"''r*"^''""  ""l' j-""'P''-'«  ^''^        Hoblyn's  Dictionarv  has  long  been  a  favorite  With 
ordinar)  c,m,u\taUon.-Charleston  Med.  Joum.  „,      n>,g  „,p  ,,^^,  ,,„„k  „(  jeffnitions  we  have,  and 

We  know  of  no  dictionary  belter  arranged  and    ought  always   to   be   upon   the    student's  table. — 
•itapted.  Itisnotincumbered  with  the  obsoleteterms  i  Southtm  Med.  and  Surg.  Journal. 
of  a  bygone  age,  but  it  contains  all  that  are  now  in  ■ 

HOLLAND'S  MEDICAL  NOTES  AND  RE- 
FLECTIONS. From  the  Ihitd  L.mdon  edition. 
Id  o6c  handsome  ocluvo  volume,  extra  clo'.h.  S:5. 

HORNER'S   SPECIAL   ANATOMY   AND    HIS- 


TOLOGY. Eighth  edition.  Extensivly  revised 
and  moditied.  In  two  large  octavo  volc.mes,  ex- 
tra cloth,  of  more  than  1000  pages,  with  over  300 
illustratiuna.     S6  00. 


HABERSHON  (S.  O.),  M.  D., 

Assistant  Physician  to  and  Lecturer  on  .Materia  .Mediea  and  Tlier;i|ieutics  at  Guy 's  Hospital,  4c. 

PATHOLOGICAL  AND  PRACTICAL  (HiSEUVATlONS  ON  DISEASES 
OF  THE  ALLMENTAHY  CANAL,  CESOPIIAGUS,  STOMACH,  C^CIJM.  AND  INTES- 
TINES. With  illuslrniions  on  Wood.  In  one  handsome  octavo  volume  of  312  pages,  extra 
cloth     $\  75.     (A'otr  Heady.) 


AND    SCIENTIFIC    PUBLICATIONS.  19 

HODGE  (HUGH    L.),   M.D., 
Professor  of  Mid%vifery  and  the  Diseases  of  Women  and  Children  in  the  University  of  Pennsylvania,  &c. 

ON    I)IS1':ASES   peculiar   to  women,  includintr  Displacements  of  the 

Uterus.     AVith  orig'inal  illustrations.     In  one  beautifully  printed  octavo  volume,  of  nearly  500 
pages.     {Now  ReaUy.) 

The  profession  will  look  with  much  interest  on  a  volume  embodying  the  long  and  extensive  ex- 
perience of  Professor  Hodge  on  an  important  branch  of  practice  in  which  his  opporinnilies  for 
investigation  have  been  so  extensive.  A  short  summary  of  the  contents  will  show  liie  scope  of 
the  Work,  and  the  manner  in  which  the  subject  is  presented.  It  will  be  seen  that,  with  the  excej)- 
tion  of  Displacements  of  the  Uterus,  he  divides  the  Diseases  peculiar  to  Women  into  iwo  great 
conslilutionai  classes — those  arising  from  irritation,  and  those  arising  from  sedation. 

CONTENTS. 

PART  I.  Diseases  of  Ikritation. — Chapter  I.  Nervous  Irritation,  and  its  Consequences — H. 
Irritable  Uterus. — III.  Local  Symptoms  of  Irritable  Uterus:  Menorrhagia  and  Hsemorrhi-^ia; 
Leucorrho?a ;  Dysnienorrhira — IV.  Local  Symptoms  of  Irritable  Uterus;  Complications. — V. 
General  Symptoms  of  Irritable  Uterus  :  Ccrebro-spniil  Irritations. — VI.  General  Symptoms  (if 
Irritable  Uierus. — VII.  Progress  and  Kesulis  of  Irritable  Uterus. — VIII.  Cau.>^es  and  Pathology 
of  Irriiable  Diseases  — IX.  Treatment  of  Irritable  Uterus;  Removal  or  Palliation  of  the  Cause. 
— X.  Treatment  of  Irritable  Uterus:  To  Diminish  or  Destroy  the  Morbid  Irritability — XI. 
Treatment  of  the  Complications  of  Irritable  Uterus. — XII.  Treatment  of  the  Complications  of 
Irritable  Uterus. 

PART  II.  Dispr.ACEMENTS  OF  THE  Uteri:s. — Chapter  I.  Natural  Position  and  Supports  of  the 
Uterus. — II.  Varieties  of  Displacements  of  the  Uterus,  and  their  Causes. — III.  Symptoms  of 
Displacements  of  the  Uterus. — IV.  Treatment  of  Displacements  of  the  Uterus. — V.  Treatment 
of  Displacements;  Internal  Supports. — VI.  Treatment  of  Ditplacements  ;  Lever  Pessaries  — 
VII.  Treatment  of  the  Varieties  of  Displacements. — VIII.  Treatment  of  Complications  of  Dis- 
placements of  the  Uterus. — IX.  Treatment  of  Enlargements  and  Displacements  of  the  Ovaries,  &c. 

PART  III.  Diseases  of  Sedation. — Chapter  I.  Sedation  and  its  Consequences:  Organic  and 
Nervous  Sedation;    Passive  Congestion;   Reaction;  Treatment — II.  Sedation  of  the  Uterus; 
Amenorrhipa:  Sedation  of  the  Uterus  from  Moral  Causes;  Sedation  of  the  Uterus  from  Physical 
Causes. — II  [.  Diagnosis  and  Treatment  of  Sedation  of  the  Uterus. 
The  illustrations,  which  are  all  original,  are  drawn  to  a  uniform  scale  of  one-half  the  natural  size. 


JONES  (T.   WHARTON),   F.  R.  S,, 

Professor  of  Ophthalmic  Medicine  and  Surgery  in  University  College,  London,  &c. 

THE  PRINCIPLES  iVND  PRACTICE  OF   OPHTHALMIC    MEDICINE 

AND  SURGERV.  With  one  hundred  and  ten  illustrations.  Second  American  from  the  second 
and  revised  London  edition,  with  additions  b/  Edward  Hartshor.n'e,  M.  D.,  Surgeon  to  Wills' 
Hospital,  &:c.     In  one  large,  handsome  royal  12mo.  volume,  extra  cloth,  of  SOU  pages.    $1  50. 


JONES  (C.   HAND  FIELD),  F.  R.  S.,  &  EDWARD   H.  SIEVEKING,   M.D., 

Assistant  Physicians  and  Lecturers  in  St.  .Mary's  Hospital,  London. 

A  MANUAL  OF  PATHOLOGICAL  ANATOMY.    First  American  Edition, 

Revised.     With  three  hundred  and  ninety-seven  handsome  wood  engravings.     In  one  large  and 
beautiful  octavo  volume  of  nearly  750  pages,  leather.     S3  75. 

Aa  a  concise  text-book,  containing,  in  a  condensed  obliged  to  glean  from  a  great  number  of  monographs, 
form,  a  complete  outline  of  what  is  Itnown  in  the  and  the  field  was  so  extensive  that  but  few  cultivated 
domain  of  Pathological  Anatomy,  it  is  perhaps  the  it  with  any  dejrree  of  success.  As  a  simple  work 
best  work  in  the  Knglish  language.  Its  great  merit  of  reference,  therefore,  it  is  of  great  value  to  the 
consists  in  its  completeness  and  brevity,  and  in  this  student  of  patholo|;ical  anatomy,  and  should  be  in 
respect  it  supplies  a  great  desideratum  in  our  lite-  ,  every  physician's  library. —  Western  Lancet. 
rature.    Heretofore   the  student  of  pathology  was  1 


KIRKES  (WILLIAM   SENHOUSE),   M.  D., 

Demonstrator  of  Morbid  Anatomy  at  St.  Bartholomew's  Hospital,  A-c. 

A    MANUAL    OF    PHYSIOLOGY.      A  new  American,  from  the   third  and 

improved  London  edition.     With  two  hundred  illustrations.     In  one  large  and  handsome  royal 
r2mo.  volume,  leather,     pp.  586.     $2  GO.     {Lately  Published.) 

This  is  a  new  and  very  much  improved  edition  of  '  One  of  the  very  best  handbooks  of  Phy8i<dogy  we 
Dr.  Kirkes'  well-knnwn  Handbook  of  Physiology,  possess — presenting  just  such  an  outline  of  the  sci- 
It  combines  conciseness  witli  completeness,  and  is,  ence  as  the  student  require?  during  his  attendance 
therefore,  admirably  adapted  for  consultation  by  the  upon  a  course  of  lectures,  or  for  reference  whilst 
busy  prartiiioner. —  Dublin  Quarterty  Journal.  preparing  for  examination— yl/7i.  Medical  Journal. 

Its  excfllence  is  in  its  compactness,  its  clearness,  For  the  student  beginning  this  study,  and  the 
and  its  caretully  cited  authorities.  It  is  the  most  practitioner  w^ho  has  but  leisure  to  refresh  his 
convenient  of  text-books.  These  gentlemen,  Messrs.  memory,  this  book  is  invaluable,  as  it  ctrntains  all 
Kirkes  and  Paget,  have  really  an  immense  talent  for  that  it  is  important  to  kn'>w,  without  special  details, 
silence,  wliieli  isnot  so  common  or  so  clieapas prat- !  which  are  read  with  interest  only  by  those  who 
^in^  people  fancy.  They  have  the  gift  of  telling  us  \  would  make  a  specialty,  or  desire  to  possess  a  criti- 
what  we  want  to  know,  without  thinking  it  neces-  cal  knowledge  of  the  subject. — Ckarleston  Med. 
sary  to  tell  us  all  they  know. — Boston  Med.  and  j  Journal. 
Surg.  Journal.  I 


20 


BLANCHARD  &  LEA'S  MEDICAL 


LAVCOOK'S  LKCTCRKS  ON  THE  PRINCI- 
PLES AND  METHODS  OF  MEDICAL  OB- 
SERVATION AND  RESEARCH.  For  the  Use 
of  Advanced  Students  and  Junior  Pniotitionerg. 
In  one  royal  Vimo.  volume,  extra  cloth.  Price $1. 


KNAPP'S  TECHNOI-OGY ;  or, Chemistry  applied 
to  the  Arts  and  to  Manufactures.  Edited  hy  Dr. 
Ro.NAi.Dn,  Dr.  RiciiAKbsoN,  and  Prof.  \\  .  R. 
JoHNso.N.  In  two  hundsomr  tivo.  vols.,  with  about 
SOU  wood' engravings.    gO  00. 

LALLEMAND  AND  WILSON. 
A    PRACTICAL    TREATISE    ON    THE    CAUSES,    SYMPTOMS,    AND 

TREATMRNT  OF  SPEKMATORRHCEA.     By  M.  Lalle.mand.     Tran.Maled  and  edited  by 

11eni!Y.I    M(l)orf;Ar.L.     Third  American  fdition.     To  which  is  added ON  DISEASES 

OF  THE  VESiCTL/E  SEMINALES;  and  their  associated  organs.  With  special  refer- 
ence to  the  Morbid  Secretions  of  the  Prostatic  and  Urethral  Mucous  Membrane.  By  Harris 
Wilson,  M.D.     In  one  neat  octavo  volume,  of  about  400  pp.,  extra  cloth.  $2  00.   (Just  Issued.) 

LA    ROCHE  (R.),    M.  D.,  &c. 
YELLOW  FEVER,  considered  in  its  Historical,  Pathological,  Etiological,  and 

Theru|)eutical  Relations.  Including  a  Skeldi  of  tiie  Disease  as  it  iias  occurred  in  Philadelphia 
from  I'iWto  IS/j-l,  with  an  examination  of  the  connections  between  it  and  the  fevers  known  under 
the  same  name  in  other  parts  of  temperate  as  well  as  in  tropical  regions.  la  two  large  and 
handsome  octavo  volumes  of  nearly  l-OOO  pages,  extra  cloth.     $7  00. 


nunt  and  unmana'jeable  disease  of  modern  times, 
has  for  several  years  been  prevailing  in  our  country 
to  a  greater  extent  than  ever  before;  that  it  is  no 
longer  confined  to  either  large  or  small  cities,  but 
penetrates  country  villages,  plantations,  and  farm- 
houses; that  it  is  treated  with  scarcely  better  suc- 
cess now  than  thirty  or  forty  years  ago;  that  there 
is  vast  mischief  done  by  ignorant  pretenders  to  know- 
ledge in  regard  to  the  disease,  and  in  vie  w  of  the  pro- 
bability tliat  a  majority  of  southern  physicians  will 
be  called  upon  to  treat  the  disease,  we  trust  that  this 
able  and  comprehensive  treatise  will  he  very  gene- 
rally read  in  the  south. — Memphis  Med.  Recorder. 


From  Professor  S.  II.  Dickson,  f'harleston,  S.  C, 

Sfplember  18,  1K55. 
A  monument  of  intelligent  and  well  applied  re- 
■eareli,  almost  without  example.  It  is,  indeed,  in 
itself,  a  large  library,  and  is  destined  to  constitute 
the  special'  resort  as  a  book  of  reference,  in  the 
lubjcct  of  which  it  treats,  to  all  future  time. 

We  have  not  time  at  present,  engaged  as  we  are, 
by  dai-  and  by  night,  in  the  work  of  combating  this 
very  disease,  now  prevailing  in  our  city,  to  do  more 
than  give  this  cursory  notice  of  what  we  consider 
as  undoubtedly  the  most  able  and  erudite  medical 
publication  our  country  has  yet  produced.  But  in 
view  of  the  startlinu;  fact,  that  this,  the  most  malig-  I 

BY  THE  SAME  ATJ-^HOR. 

PNEUMONIA  ;  its  Supposed  Connection,  Pathological  and  Etiological,  with  Au- 
tumnal Fevers,  including  an  Inquiry  into  the  Existence  and  Morbid  Agency  of  Malaria.  In  one 
handsome  octavo  volume,  extra  doth,  of  500  pages.    $3  00. 

LUDLOW  (J.   L.),   M.  D. 
A   MANUAL   OF    EXAMINATIONS   upon   Anatomy,   Physiology,    Surgery, 

Practice  of  Medicine,  Ob.'^tetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and  Therapeutics.  To 
which  is  added  a  Medical  Formulary.  Third  edition,  thorousjhly  revised  and  greatly  extended 
and  enlarged.  With  370  illustrations.  In  one  handsome  royal  12mo.  volume,  leather,  of  816 
large  pages,     $2  00. 

The  (Treat  popularity  of  this  volume,  and  the  numerous  demands  for  it  during  the  two  years  in  which 
It  has  been  out  o(  print,  have  induced  the  author  in  its  revision  to  spare  no  pains  to  render  it  a 
correct  and  accurate  digest  of  the  most  recent  condition  of  all  the  branches  of  medical  science.  In 
many  resp«Tis  it  may.  therefore,  be  regarded  rather  as  a  new  book  than  a  new  edition,  an  entire 
section  on  Physiology  having  been  added,  as  also  one  on  Organic  Chemistry,  and  many  portions 
having  I)een  rcwritlen.  A  very  complete  series  of  illustrations  has  l>een  introduced,  and  every 
care  has  t>cen  taken  in  the  mechanical  execution  to  render  it  a  convenient  and  satisfuciory  book  for 
study  or  reference.  The  arrangement  of  the  volume  in  the  form  of  (piestion  and  answer  renders  it 
especially  suited  for  the  olfice  examination  of  students  and  for  those  preparing  for  graduation. 

We  know  of  no  better  companion  for  the  student  I  crnmmtd  into  his  head  by  the  various  professors  to 
during  the  hours  spent  in  the  lecture  room,  or  to  re-  whom  he  is  compelled  to  listen. —  WesUm  Lancet, 
fresh,  at  a  glance,  his  memory  of  the  various  topics  |  May,  1857. 


LEHMANN   (C.  G.) 
PHYSIOLOGICAL    CHEMISTRY.      Translated  from  the   second   edition   by 

Georoe  E.  Day,  M.  D.,  F.  R.  S.,  >.Vc.,  edited  by  R.  E.  Rogers,  M.  D.,  Professor  of  Chemistry 
in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustrations  selected  from 
Fiinke's  Atlas  of  Physiological  Chemistry,  and  an  Ap|)en(lix  of  plates.  Complete  in  two  large 
and  handsome  octavo  volumes,  extra  cloth,  containing  1200 pages,  with  nearly  two  hundred  illus- 
trations.    $t)  00. 


The  work  of  I.rhmann  stands  unrivalled  as  the 
most  coniprehenKi  ve  book  of  reference  and  informa- 
tion extant  on  every  branch  of  the  subject  on  which 
it  ttcat*.— Edinburgh  J oumnl  of  Medical  Science. 


The  most  important  contribution  as  yet  made  to 
Physiological  Chemistry Am.  Journal  Med.  Sci- 
ences, Jan.  1S56. 


BY  THE  SAME  AUTHOR.      (Tjiltfly  Puhlishfd.) 

MANUAL  OF  CHEMICAL   PHYSIOLOGY.      Translated  from  the  German, 

with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  liilrodticlory  Essay  on  Vital 
Force,  by  Professor  Samiel  Jackson,  M.  D.,  of  the  University  o(  Pennsylvania.  With  illus- 
trations on  wood.     In  one  very  handsome  octavo  volume,  extra  cloth,  of  336  pages.     $2  25. 

Frctr.  Pre/.  Jaci'sou's  Introductory  Ex.^ny, 
In  adopting  the  handbook  of  Dr   Lehnmnn  as  a  manual  of  Organic  Chemistry  for  the  use  of  the 
etudenls  of  the  University,  and  in  recommending  his  original  work  of  Physiological  Chemistry 
for  their  more  mature  studies,  the  high  value  of  his  researches,  and  the  great  weight  of  his  autho- 
rity in  that  important  department  of  medical  science  are  fully  recognized. 


AND    SCIENTIFIC    PUBLICATIONS. 


21 


LAWRENCE  (W.),   F.  R.  S.,  Slc. 
A  TREATISE    ON    DISEASES    OF    THE    EYE.     A    new  edition,  edited, 

with  numerous  additions,  and  243  illustrations,  by  Isaac  Hays,  M.  U.,  Surgeon  to  Will's  Hospi- 
tal, &c.  In  one  very  lar^e  and  handsome  octavo  volume,  of  950  pages,  strongly  bound  in  leather 
with  raised  bands.    $5  00.  

MEIGS  (CHARLES  D.),  M.D., 

Professor  of  Obstetrips,  &c.  in  the  .leflTerBon  Medical  College,  Philadelphia. 

OBSTETRICS :   THE   SCIENCE   AND   THE   ART.     Third  edition,  revised 

and  improved.   With  one  hundred  and  twenty-nine  illustrations.  In  one  beautifully  printed  octavo 

volume,  leather,  of  seven  hundred  and  fifty-two  large  pages.     $3  75. 

The  rapid  demand  for  another  edition  of  this  work  is  a  sutTicient  expression  of  the  favorable 
verdict  of  the  profession.  In  thus  preparing  it  a  third  time  lor  the  press,  tne  author  has  endeavored 
to  render  it  in  every  respect  worthy  of  the  favor  which  it  has  received.  To  accomplish  this  he 
has  thoroughly  revised  it  in  every  part.  Some  portions  have  been  rewritten,  others  added,  new 
illustrations  have  been  in  many  instances  substituted  for  such  as  were  not  deemed  satisfactory, 
while,  by  an  alteration  in  the  typographical  arrangement,  the  size  of  the  work  has  not  been  increased, 
and  the  price  remains  unaltered.  In  its  present  improved  form,  it  is,  therefore,  hoped  that  the  work 
will  continue  to  meet  the  wants  of  the  American  prolession  as  a  sound,  practical,  and  extended 
System  of  Midwifery. 


Though  the  work  has  received  only  five  pages  of 
enlargement,  its  chapters  throughout  wear  the  im- 
pressof  careful  revision.  E.xpunging  and  rewriting, 
remodelling  its  sentences,  with  occasional  new  ma- 
terial, all  evince  a  lively  desire  that  it  shall  deserve 
to  be  regarded  as  improved  in  maniier  as  well  as 
matur.  In  the  matter,  every  stroke  of  the  pen  has 
increased  the  value  of  the  book,  both  in  e.\pungings 
and  additions  — Western  Lancet,  Jan.  1857. 


The  best  American  work  on  Midwifery  that  is 
accessible  to  the  student  and  practitioner — N.  W. 
Med.  and  Surg.  Journal,  Jan.  lSo7. 

This  is  a  standard  work  by  a  great  American  Ob- 
stetrician. It  is  the  third  and  last  edition,  and,  in 
the  larguage  of  the  preface,  the  author  has  '-brought 
the  subject  up  to  the  latest  dates  of  real  improve- 
ment in  our  art  and  Science." — Nashville  Journ.  of 
Med.  and  Surg.,  May,  1857. 

BY   THE  SAME   AUTHOR.      {J/iSt  Is.ilted.) 

WOMAN :  HER  DISEASES  AND  THEIR  RE3IEDIES.  A  Series  of  Lee- 
tures  to  his  Class.  Fourth  and  Improved  edition.  In  one  large  and  beautifully  printed  octav© 
volume,  leather,  of  over  700  pages.     $3  60. 


In  other  respects,  in  our  estimation,  too  much  can- 
not be  said  in  pr.iise  of  this  work.  It  abounds  with 
beautiful  passages,  and  for  conciseness,  for  origin- 
ality, and  for  all  that  is  commendable  in  a  work  on 
the  diseases  of  females,  it  is  not  excelled,  and  pro- 
bably not  equalled  in  the  English  language.  On  the 
whole,  we  know  of  no  woru  on  the  diseases  of  wo- 
men which  we  can  so  cordially  commend  to  the 
student  iind  practitioneras  the  one  before  us. — Ohio 
Med.  and  Surg.  .Journal. 

The  body  of  the  book  is  worthy  of  attentive  con- 
sideration, and  is  evidently  the  production  of  a 
clever,  thoughtt'ul,  and  sagacious  physician.  Dr. 
Meigs's  letters  on  the  diseases  of  the  external  or- 
gans, contain  many  interesting  and  rare  cases,  and 

many  instructive  observations.     We  take  our  leave     __ ^   _ 

of  Dr.  Aleigs,  with  a  high  opinion  of  his  talents  and     Charleston  Med.  "Journal 
originality. — The  British  and  Foreign  Medico-Chi- 
ruTgical  Revieio. 

Every  chapter  is  replete  with  practical  instruc- 
tion, and  bears  the  impress  of  being  the  composition 
of  an  acute  and  experienced  mind.  There  is  a  terse 
ness,  and  at  the  same  time  an  accuracy  in  his  de 


Full  of  important  matter,  conveyed  in  a  ready  and 
agreeable  manner.— St. Lonis  Med.  and  Surg.  Jour. 

There  is  an  off-hand  fervor,  a  glow,  and  a  warm- 
heartedness infecting  the  efr)rt  of  Dr.  Meigs,  which 
is  entirely  captivating,  and  which  absolutely  hur- 
ries the  reader  through  from  beginning  to  end.  Be- 
sides, the  book  teems  with  solid  instruction,  and 
it  shows  the  very  highest  evidence  of  ability,  viz., 
the  clearness  with  which  the  information  is  pre- 
sented. We  know  of  no  better  test  of  one's  under- 
standing a  subject  than  the  evidence  of  the  power 
of  lucidly  explaining  it.  The  most  elementary,  as 
well  as  the  obscurest  subjects,  under  the  pencil  of 
Prof.  Meigs,  are  isolated  and  made  to  stand  out  in 
such  bold  relief,  as  to  produce  distinct  impressions 
upon  the  mind  and  memory  of  the  reader.  —  Tht 


Professor  Meigs  has  enlarged  and  amended  thi« 
great  work,  for  such  it  unquestionably  is,  having 
passed  the  ordeal  of  criticism  at  home  and  abroao, 
but  been  improved  thereby  ;  for  in  this  new  edition 
the  author  has  introduced  real  improvements,  and 
increased  the  value  and  utility  of   the  book  im- 


scription  ot  symptoms,  and  in  the  rules  for  diagnosis,  Ljjeagurably.  It  presents  so  many  novel,  bright, 
which  cannot  fail  to  recommend  the  volume  to  the  „„j  sparkling  thoughts;  such  an  exuberance  of  new 
attention  of  the  reader.— Ratik in g's  Abstract.  j  jjg^g  „„  almost  every  page,  that  we  confess  ouT- 

It  contains  u  vast  amount  of  practical  knowledge.  ,  selves  to  have  become  enamored  with  the  book 
by  one  who  has  accurately  observed  and  retained  !  and  its  author;  and  cannot  withhold  tiur  congratu- 
the  experience  of  many  years. — Dublin  Quarterly  lations  from  our  Philadelphia  confreres,  that  such  a 
Journal.  teacher  is  in  their  Bervice. — N.  Y.  Med.  Gazett*. 

BY   THE  SAME   AUTHOR. 

ON    THE    NATURE,    SIGNS,    AND    TREATMENT    OP    CHILDBED 

FEVER.     In  a  Series  of  Letters  addressed  to  the  Students  of  his  Class.    In  one  handsome 
octavo  volume,  extra  cloth,  of  365  pages.     $2  50. 


The  instructive  and  interesting  author  of  this 
work,  whose  previous  labors  have  placed  his  coun- 
trymen under  deep  and  abiding  obligations,  again 
challenges  their  admiration  in  the  fresh  and  vigor- 
ous, attractive  and  racy  pages  before  us.   it  is  a  de- 


lectable book.  *  *  «  This  treatise  upon  child- 
bed fevers  will  have  an  extensive  sale,  being  des- 
tined, as  it  deserves,  to  find  a  place  in  the  library 
of  every  practitioner  who  scorns  tolag  in  the  rear. — 
Nashville  Journal  of  Medicine  and  Surgery. 


BY   THE   SAME   AttTHOR  ;    WITH  COLORED  PLATES. 

A  TREATISE  ON  ACUTE  AND  CHRONIC  DISEASES  OF  THE  NECK 

OF  THE  UTERUS.     With  numerous  plates,  drawn  and  colored  from  nature  in  the  highest 
style  of  art.     In  one  handsome  octavo  volume,  extra  cloth.     $4  50. 


MAVNR'S  DISPENSATORY  AND  THERA- 
PEUTICAL REME.MBRaNCER.  Witheverv 
Practical  Formula  contiiined  in  the  three  British 
Pharmacopoeias.  Edited,  with  the  addition  of  the 
Formulae  of  the  U.  3.  Pharmacopoeia,  by  R.  E. 
GKirriTHjM.D.   1 12mo.  vol.  ex. cl.,. 300pp.  75  c. 


MALGAIGNE'S  OPERATIVE  SURGERY.based 

on  Normal  and  Pathological  Anatomy.  Trans- 
lated from  the  French  by  Frederick  Brittan, 
A.  B.,M.  D.  With  numerous  illustrations  on  wood. 
In  one  handsome  octavo  volume,  extra  cloth,  of 
nearly  six  hundred  pages.    B'i  25. 


22 


BLANCHARD    ic    LEA'S    MEDICAL. 


MACLISE  (JOSEPH),    SURGEON. 
SURGICAL  ANATOMY.     Forming  one  volume,   very  large  imperial   quarto. 

With  -ixiy-eighi  large  and  i^plendid  PUiie>,  drawn  in  the  best  style  and  beautilully  colored.    Con- 
taining one  hundred  and  ninety  Figure*,  many  of  them  the  size  of  lile.     Together  with  copious 
and  explanatory  letter-press.     Strongly  and   handsomely  bound   in  extra  cloth,  being  one  of  the 
cheape-t  and  l)«,'st  executed  Surgical  works  as  yet  issued  in  this  country.    Sll  00. 
•,•  The  size  ofthi*  work  prevents  its  transmi>sion  through  the  post-olRce  as  a  whole,  but  those 

who  desire  to  have  copies  Ibrwarded  by  mail,  can  receive  them  in  five  parts,  done  up  in  stout 

wrappers.     Pnw  S^  00. 
One  of  the  (frratcit  artistic  triuiiiphi  of  the  age        A  work  which  has  no  parallel  in  point  of  accu- 

in  Surgical  Anatomy.— BririsA  American  Medical    racy  and  cheapness  in  the  English  language.— iV.  y. 

Journal.  Journal  of  Medicint. 

No  praclitlonrr  whn«r  menns  will  admit  should 


fail  to  piisums  it. —  Knnking's  Abstract. 

T<">  much  ciinnot  tie  suid  in  its  praise;  indeed, 
we  havr  not  liineuiige  to  do  it  justice. — OMo  Medi- 
cal and  Surgical  Journal. 

The  most  accurately  engraved  and  beautifully 
colored  pliiles  we  hiive  ever  seen  in  an  American 
book — one  of  the  hest  and  cheapest  surgical  works 
ever  publishe<l. — Bu_ffalo  Medical  Journal. 


It  ii  very  rare  that  so  elegantly  printed,  so  well 
lustrate<l,  and  fo  useful    a  work,   is   ofTered  a 
moderate  a  price. — Charleston  Medical  Journal. 


We  are  extremely  gratified  to  announce  to  the 
profession  the  completion  of  this  truly  magnificeiit 
work,  which,  as  a  whole,  certiinly  stands  unri- 
valled, both  for  accuracy  of  drawing,  beauty  of 
coloring,  and  all  the  requisite  explanations  of  the 
subject  in  hand. — Tki  I\'et»  Orleans  Medical  and 
Surgical  Journal. 

This  is  by  far  the  ablest  work  on  Surgical  Ana- 
tomy  that  has  come   under  our  observation.    We 


know  of  no  other  work  that  would  justify  a  stu- 
illustrateil.'and  so  useful   a  "work, 'is  offered  at  so    dent,  in   any  degree,  for  neglect  of  actual  dissec- 


tion.    In   those  sudden  emergencies  that   so  often 

arise,  and  which  require  the  instantaneous  command 

Its  Dlatcs  can  bonst  a  superiority  which  places    „f  minute  anatomical  knowledge,  a  work  of  this  kind 

them  almost  lieyond  the  reach  of  competition —Afedt-    ^^^pg  the  dcHiils  of  the  disEccting-room  perpetually 

eal  Examiner.  ffj.gl,  ;„  ti,g  memory .-r^e  Western  Journal  of  Midi- 

Country  practitioners  will  find  these  plates  of  im-     cine  and  Surgery. 
mense  value. — y.  Y.  Medical  Gazette.  ' 

MILLER  (HENRY),  M.  D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  University  of  Louisville. 

PRINCIPLES  AND  PRACTICK  OF  OBSTETRICS,  &c.;  including  the  Treat- 

menl  of  Chronic  Intlummalion  of  the  Cervix  and  Body  of  the  Uterus  considered  as  a  frequent 

caus«;  of  Abortion.     With  about  one  hundred  illustrations  on  wood.     In  one  very  handsome  oc- 

lovo  volume,  of  over  600  pages.     (Lately  Published.)     $3  75. 

The  rcpulutioii  of  Dr.  Miller  as  an  obstetrician  is  too  widely  spread  to  require  the  attention  oi 
the  prole>>i('n  to  be  specially  called  to  a  volume  containing  ihe  experience  of  his  long  and  extensive 
practice.  The  very  I'avorable  reception  accorded  to  his  "  Treatise  on  Human  Parturition,"  issued 
some  years  since,  is  an  earnest  that  the  present  work  will  fulfil  the  author's  intention  of  providing 
within  a  moderate  compass  a  complete  and  trustworthy  text-book  for  the  student,  and  book  of  re- 
lerence  for  the  practitioner. 

We  congratulate  the  author  that  the  task  is  done.  '  tion  to  which  its  merits  justly  entitle  it.  The  style 
We  congru'iiluie  him  that  he  hasgiven  to  the  medi-  is  such  that  the  descriptionsare  clear,  and  each  sub- 
cal  public  a  work  which  will  secure  for  him  a  high  ject  is  discussed  and  elucidated  with  due  regard  to 
anil  permau'-nt  position  among  the  standard  autho-  its  practical  bearincrs,  which  cannot  fail  to  make  it 
rities  on  the  principles  and  practice  of  obstetrics,  acceptable  and  valuable  to  both  students  and  prac- 
Conpralulaliiins  are  not  less  due  to  the  medical  pro-  titioncrs.  We  cannot,  however,  close  this  brief 
fession  of  ihm  C'luntry,  on  Ihe  acquisili<m  of  a  trea-  notice  without  congratulating  the  author  and  the 
tiscemboilyin?  the  results  of  the  studies,  reflections,  profession  on  the  production  of  such  an  excellent 
and  experience  of  Prof.  Miller.  Few  men,  if  any,  treatise.  The  author  is  a  western  man  of  whom  we 
in  this  Country,  are  more  Competent  than  he  to  write  feel  proud,  and  we  canni>t  but  think  that  his  book 
on  thiidepartdieni  of  medicine.  Kngaged  for  thirty-  will  find  many  readers  and  warm  admirers  wherever 
five  years  in  an  extended  practice  of  uhstetrics,  for  obstetrics  is  tonight  and  studied  as  a  science  and  an 
many  years  a  teacher  of  this  branch  of  instruction  art. — TheCincinnati  Lancttand  Observer, Fe\).\65&. 
in  one  of  the  lar-.st  of  our  institutions,  a  diligent  ^  most  respectable  and  valuable  additi.m  to  our 
studentaswrlasacarefu  observer,  an  originaland  ^ome  medical  literature,  and  one  reflecting  credit 
independent  thinker,  wedded  to  no  hohbies,  ever  „|,ke  on  the  author  and  the  institution  to  wnich  he 
ready  to  consider  witho.it  prejudice  new  views,  and  jg  attached.  The  student  will  find  in  this  work  a 
toadopt  innovntionMf  they  arc  really  impr..ve.iients,  most  useful  guide  to  his  studies:  the  country  prae- 
and  withal  a  clear,  agreeal.le  writer,  a  practica.  tiiioner,  rusty  in  his  reading,  can  obtain  from  its 
treatise  from  his  pen  could  not  fail  to  possess  great  p„„eg  „  (^^f  resume  of  the  modern  literature  of  the 
vn\ue. -Ruftalo  Med  Journal,  Mrt.  }bS8.  scence;  and  we  hope  to  see  this  American  produc- 

In  fact,  this  volumeniust  take  its  place  among  the  tion  generally  consulted  by  the  profession. —  Ya. 
■tandard  systematic  treatises  on  obstetrics ;  a  posi-  '  Med.  Journal,  Feb.  1868. 

MACKENZIE   (WJ,    M.D., 

Surgeon  Oculist  in  Scotland  in  onlinary  to  Her  Majesty,  Ac.  Ac. 

A  PRACTICAL   TREATISE  ON    DISEASES   AND  INJURIES  OF   THE 

EYE.  To  which  is  prefixed  an  Anatomical  Introduction  explanatory  of  a  Horiziinlal  Section  ol 
the  Human  Eyeball,  by  Thomas  Wharton  Jonks,  F.  R.  S.  From  the  Fourth  Revised  and  En- 
larged I.,oii(lon  Edition.  With  Notes  and  Additions  by  Addinf.ll  Hewson,  AL  D.,  Surgeon  to 
Wills  Hospital,  Arc.  i:c.  In  one  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  with 
plates  and  numeroU!«  wood-cuts.     $•'3  '^5. 

The  treatise  of  Dr.  .Mackenzie  indisputably  holds  '  able  manner  in  which  the  author's  stores  of  learning 
the  first  place,  and  forms,  in  respect  of  learning  and  and  experience  were  rendered  available  lor  general 
research,  an  Knryclop.Tdia  unequalled  in  extent  by     use,  at  once  procured  l"or  the  first  edition,  as  well  on 

the  cimiinent  as  in  this  country,  that  hich  position 
as  a  standard  work  which  each  succesHive  edition 
has  more  firmly  established.  We  consider  it  the 
duty  of  evcrv  one  wlio  has  the  love  of  hu  profession 
and  the  welfare  of  his  patient  at  heart,  to  make  him- 
self familiar  with  this  the  most  complete  work  in 
the  English  language  upon  the  diseases  of  the  eye. 


any  other  work  of  the  kind, either  English  or  foreign. 
— biroH  on  Di-'ttsfs  of  the  Eft. 

Few  mixirm  books  on  any  department  of  medicine 
or  surgery  have  met  with  such  extended  circulation, 
or  have  procured  for  their  authors  a  like  amount  of 
European  celcliritv.     The  immense  .  :search  wh.ch 

it   displayed,  the  thorough   acquaintance  with   the    ">'  tnglisii   language  upoi 
•abject,  practically  as  well  as  •^-   — 'ioally.and  the'— ^"'-  Titntsand  liazettt 


AND    SCIENTIFIC    PUBLICATIONS. 


26 


MILLER  (JAMES),   F.  R.S.E., 

Professor  of  Surgery  in  the  University  of  Edinburgh,  fee. 

PKINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and  revised 

Edinburgh  edition.    In  one  large  and  very  beautilul  volume,  leather,  of  700  pages,  with  two 
hundred  and  forty  illustrations  on  wood.     $3  75. 


The  work  of  Mr.  Miller  is  too  well  and  too  favor- 
ably known  among  us,  as  one  of  our  best  text-books, 
to  render  any  further  notice  of  it  necessary  than  the 
announcement  of  a  new  edition,  the  fourth  in  our 
country,  n  proof  of  its  extensive  circulation  among 
us.  As  a  concise  and  reliable  exposition  of  the  sci- 
ence of  modern  surgery,  it  stands  deservedly  high — 
we  know  not  its  superior. — Boston  Med.  and  Surg. 
Journal. 


The  work  takes  rank  with  Watson's  Practice  of 
Physic;  it  certainly  does  not,  fall  bcliiiut  tluit  great 
work  in  soundness  of  principle  or  deplh  of  reason- 
ing and  research.  No  physician  w\n>  v.ilues  his  re- 
putation, or  seeks  tlie  interests  of  his  clients,  can 
acquit  himself  before  his  God  and  the  world  without 
m.iking  himself  familiar  with  the  soand  and  philo- 
sophical views  developed  in  the  foregoing  book. — 
I  New  Orleans  Med.  and  Surg.  Journal. 

BY   THE  SAME   AUTHOR.      {Jllst  Issued.) 

THE   PRACTICE   OF   SURGERY.      Fourth  American  from  the  last  Edin- 

burgh  edition.     Revised  hy  the  Anierican  editor.     Illustrated  by  three  hundred  and  sixty-four 
engravings  on  wood.     In  one  large  octavo  volume,  leather,  of  nearly  700  pages.     $3  75. 
No  encomium  of  ours  could  add  to  the  popularity  :  his  works,  both  on   tlie  principles  nn<l  practice  of 
of  Miller's  Surgery.     Its  reputation  in  this  country  |  surgery  have  been  assigned  tliehigliest  rank.     If  we 


is  unsurpassed  by  that  of  any  other  work,  and,  when 
taken  in  connection  with  the  author's  Principles  of 
Surgery.,  eonslitutes  a  whole,  withcmt  rel'ercnce  to 
to  which  no  conscientious  surgeon  woald  be  willing 
practice  his  art. —  Sotttkern  Med.  and  Surg.  Journal. 
It  is  seldom  that  two  volumes  have  ever  made  so 
profound  an  impression  in  so  short  a  time  as  the 
"  Principles"  and  the  "  Practice"  of  Surgery  by 
Mr.  Miller — or  so  richly  merited  the  reputation  they 
have  acquired.  The  author  is  an  eminently  sensi- 
ble, practical,  and  well-informed  man,  who  knows 
exactly  what  lie  is  talking  about  and  exactly  how  to 
talk  it. — Kentucky  Medical  Recorder. 


By  the  almost  unanimous  voice  of  the  profession,  |  Sciences. 


were  limited  to  but  one  work  on  sursfcry,  that  one 
should  be  Miller's,  as  we  regard  it  as  superior  to  all 
others. — St.  Louis  Med.  and  Surg.  Journal. 

The  author  has  in  this  and  his"  Principles,"  pre- 
sented to  the  profession  one  of  the  most  complete  and 
relialile  systems  of  Surgery  extant.  His  style  of 
writing  is  original,  impressive,  and  engaging,  ener- 
getic, c<mcise,  and  lucid.  Few  have  flic  faculty  of 
condensing  so  much  in  small  space,  and  at  the  same 
time  so  persistently  holding  tlieattention.  Whether 
as  a  text-book  tor  students  or  a  book  of  reference 
for  practitioners,  it  cannot  be  too  strongly  recom- 
mended.— Southern  Journal  of  Med.  and  Physical 


MORLAND   (W.  W.),   M.   D., 

Fellow  of  the  Massachusetts  Medical  Society,  &C.. 

DISEASES  OF  THE  URINARY  ORGANS ;  a  Compendium  of  their  Diagnosis, 

Pathology,  and  Treatment.     With  illustrations.     In  one  large  and  handsome  octavo  volume,  ol 
about  6()0  pages,  extra  cloth.     (Just  Issued.)     $3  50. 
Taken  as  a  whole,  we  can  recommend  T)r.  Mor 


land's  compendium  as  a  very  desirable  addition  to 
the  library  of  every  im-dical  or  surgical  practi- 
tioner.— Brit,  and  For.  Med.-Chir.  Rev.,  April,  1859. 
Every  medical  practitioner  \vhose  attention  has 
been  to  any  extent  attracted  towards  the  class  of 
diseases  to  which  this  treatise  relates,  must  have 
often  anil  sorely  experienced  the  want  of  some  full, 
yet  concise  r*cent  compendium  to  which  he  cimld 
refer.    This  desideratum  has  been  sunplied  by  Dr 


yet  in  a  succinct,  narrational  style,  such  as  to  render 
the  work  one  of  great  interest',  and  one  which  will 
prove  in  ttie  highest  degree  useful  to  the  general 
practitioner.  To"  the  members  of  ilie  profession  in  the 
country  it  will  be  peculiarly  valuable,  on  account 
of  the  characteristics  which  we  have  mentioned, 
and  the  one  broad  aim  of  practical  utility  which  is 
kept  in  view,  and  which  shines  out  upon  every  page, 
toeether  with  the  skill  which  is  evinced  in  the  com- 
bination  of  this  grand  requisite   with   the   utmost 


Morland.  and  it  has  been  ab'ly  done.     He  has  placed  |  l^^evity  whicha  just  treatment  of  the  subjects  would 
before   us  a  full,  judicious,  and    reliable    ^\\.re^t.\^<^»iil—N.Y.Journ.ofMedtctnt,-\ov.ViS». 
Each  subject  is  treated  with  sutficient minuteness,  I 


MONTGOMERY  (W.  F.),    M.  D.,   M.  R.  I.  A.,  Slc, 

Professor  of  Midwifery  in  the  King  and  Queen's  College  of  Physicians  in  Ireland,  &c. 

AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 

Wilh  some  other  Papers  on  Subjects  connected  with  Midwifery.     From  the  seeoiul  and  enlarged 
English  edition.     Wilh  two  exquisite  colored    plates,  and  luiiiierous  wood-cuts.     In  one  very 
handsome  octavo  volume,  extra  cloth,  of  nearly  600  pages.     {Lately  PiMislifd.)    $3  75. 
A  book  unusually  rich  in  practical  suggestions. —  I  has  been  weighed  and  reweiglied  thr<mgh  years  of 
Am.  Journal  Med.  Sciences,  Jan.  1857.  preparation;  that  this  is  of  all  others  the  book  of 

These  several   subjects  so   interesting  in   them- !  "''^'efie  Law,  on  each  of  its  several  topics ;  on  all 


selves,  and  so  important,  every  one  of  them,  to  the 
most  delicate  and  precious  of  social  relations,  con- 
trolling olten  the  honor  and  domestic  peace  of  a 
family,  the  legitimacy  of  offspring,  or  the  life  of  its 
parent,  are  all  treated  with  an  elegance  of  diction, 
fulness  of  illustrations,  acutenessand  justice  of  rea- 
soning, unparalleled  in  obstetrics,  and  unsurpassed  in 
medicine.  The  reader's  inti-rest  can  never  flag,  so 
fresh,  and  vigorous,  and  classical  is  our  author's 
style  ;  and  one  forgets,  in  the  renewed  ch;irin  of 
every  page,  that  it,  and  every  line,  and  every  word 


points  connected  with  pregnancy,  to  be  everywhere 
received  as  a  manual  of  speci.al  jurisprudence,  at 
(mce  announcing  fact,  affording  argument,  establish- 
ing precedent,  and  governing  alike  the  juryman,  ad- 
vocate, and  judije.  It  is  not  merely  in  its  legal  re- 
lations that  we  find  this  work  s<i  interesting.  Hardly 
a  page  but  that  has  its  hints  or  facts  important  to 
the  general  practitioner;  and  not  a  chapter  without 
especial  matter  for  the  anatomist,  physiologist,  or 
pathologist. — iV.  A.  Med.-Chir.  Revieto,  March, 
1857. 


MOHR  (FRANCIS),  PH.  D.,  AND   REDWOOD  (TH  EOPH  I  LUS). 
PRACTICAL    PHARxMACY.     Comprising  the  Arrangements,  Apj.aratus,  and 

Manipulations  of  the  Pharmaceutical  Shop  and  Laboratory.  Edited,  with  exlen>ive  Additions, 
by  Prof  WiLLiA.M  Procter,  of  the  Philadelphia  College  of  Pharmacy.  In  one  handsomely 
printed  octavo  volume,  extra  cloth,  oi  570  pages,  wilh  over  500  engravings  on  wood.    $2  75. 


24  BLANCHARD   &    LEA'S   MEDICAL 


NEILL  (JOHN),   M.  D., 

Surgeon  to  the  Pennsylvania  Hospital, 4c.;  and 

FRANCIS  GURNEY   SMITH,   M.D., 

Professor  of  Iiislitutcs  of  Medicine  in  the  Pennsylvania  Medical  College. 

AN  ANALYTKWL   COMPENDIUM    OF   THE    VARIOUS   BRANCHES 

OK  MEDICAL  !?C1ENCE;  for  the  Use  ami  Examination  of  Students.     A  new  edition,  revised 

and  improved.     In  one  very  large  and  handsomely  printed  royal  12mo.  volume,  ol  about  one 

thousand  pages,  with  374  wood-cuts.     Strongly  bound  in  leather,  with  raised  bands.     $3  00. 

The  very  tiattering  reception  which  ha«  been  accorded  to  this  work,  and  the  high  estimate  placed 
upon  it  by  the  profession,  as  evinced  by  the  constant  and  increasing  demand  which  has  rapidly  ex- 
hausted two  large  editions,  have  stimulated  the  authors  to  render  the  volume  in  its  present  revision 
more  worthy  o(  the  success  which  ha.s  attended  it.  It  has  accordingly  been  thoroughly  examined, 
and  such  errors  as  had  on  former  occasions  escaped  observation  have  been  corrected,  and  whatever 
additions  were  necessarv  to  maintain  it  on  a  level  with  the  advance  ofscience  have  been  introduced. 
The  extended  .series  of  illu>trations  has  been  still  further  increased  and  much  improved,  while,  by 
a  slight  enlargement  of  the  pjige,  these  various  additions  have  been  incorporated  without  increasing 
the  bulk  of  the  volume. 

The  work  is,  therefore,  again  presentedaseminently  worthy  of  the  favor  with  which  it  has  hitherto 
been  received.  As  a  book  for  daily  reference  by  the  student  requiring  a  guide  to  his  more  elaborate 
text-books,  as  a  manual  for  preceptors  desiring  to  stimulate  their  students  by  frequent  and  accurate 
examination,  or  as  a  source  /rom  which  the  practitioners  of  older  date  may  easily  and  cheaply  acquire 
a  knowledge  of  the  changes  and  improvement  in  professional  science,  its  reputation  is  permanently 
established. 

The  best  work  of  the  kind  with  which  we  are  ]  the  students  is  heavy,  and  review  necessary  for  an 
acquninlrd. —  Med.  Examiner.  examination,  a  compend  is  not  only  valuable,  but 

Having  made  free  use  of  this  volume  in  our  ex-  I' '»  alm.-st  a  sine  qua  non  The  one  before  us  is, 
aminati.fns  of  pupils,  we  can  speak  from  experi-  "I ™?l°^"'^^'V^"'"«'  '^*  |""^'  unexceptionable 
ence  in  r^com.iu-mling  it  as  an  admirable  compend  "f  »"  book*  of  the  kind  that  we  know  of.  The 
for  students,  and  as  especially  useful  to  preceptors  "e^est  and  soundest  doctrines  and  the  atest  ira- 
who  examine  their  pupils.  It  will  save  the  teacher  provements  and  discoveries  are  explicitly,  though 
much  labor  by  enal'liiig  him  readily  to  recall  all  of  .  concisely,  laid  before  the  student.  There  is  a  class 
the  points  upon  whicTi  his  pupils  should  be  ex-  to  whom  we  very  sincerely  commend  this  cheap  book 
amined.  A  w..rk  of  this  sort  should  be  in  the  hands  asworth  its  weight  in  silver-that  class  is  thegradu- 
of  every  one  who  takes  pupils  into  his  office  with  a  a'^«  '»  medicine  of  more  than  ten  years'  standing. 
vtewofVxaminln?them:  and  this  isunquestionably  who  have  not  studied  medicine  since.  They  will 
the  best  of  Its  cUiiB.-Transylvania  Med.  Journal .      \  perhaps  find  out  from  it  that  the  science  is  not  exactly 

now  what  it  was  when  they  left  it  off. — Tnt  SutM- 

In  the  rapid  course  of  lectures,  where  work  for  i  scope. 


NELIGAN  (J.    MOpRE),  M.  D.,  M.  R.  I. A.,  &.C. 
{A  spleitAid  work.     Just  Issued.) 

ATLAS  OF  CUTANEOUS  DISEASES.  In  one  beautiful  quarto  volume,  extra 
cloth,  with  splendid  colored  plates,  presenting  nearly  one  hundred  elaborate  representations  of 
disea.se.    $4  50. 

This  beautiful  volume  is  intended  as  a  complete  and  accurate  representation  of  all  the  varieties 
of  Diseases  of  the  Skin.  While  it  can  be  consulted  in  conjunction  with  any  work  on  Practice,  it  has 
especial  reference  to  the  author's  "  Treatise  on  Diseases  of  the  Skin,"  so  favorably  received  by  the 
profession  some  years  since.  The  publishers  feel  justified  in  saying  that  few  more  beautifully  exe- 
cuted plates  have  ever  been  presented  to  the  profession  of  this  country. 

Nelignn's  Atlas  of  Cutanenns  Diseases  supplies  a  '  give,  at  a  toup  d^cril,  the  remarkable  peculiaritiea 
long  existent  desideratum  much  felt  by  the  largest  of  each  individual  variety.  And  while  thus  the  dii- 
class  of  our  profession.  It  presents,  in  quarto  size,  ease  is  rendered  more  definable,  there  is  yet  no  loss 
16  plates,  each  containing  from  3  to  0  figures,  and  ,  of  proporti<m  incurred  by  the  necessary  conccntra- 
forming  in  all  a  total  of  90  distinct  representations  tion.  Each  figure  is  highly  cobired.  and  so  truthful 
of  the  dilferent  species  of  skin  afTections,  grouped  has  the  artist  been  that  the  most  fast  id  ous  observer 
together  in  genera  or  families.  The  illustrations  could  not  justly  take  exception  to  the  correctness  of 
have  been  faki-n  from  nature,  and  have  leen  copied  the  execution  of  the  pictures  under  his  scrutiny. — 
with  such  fidelity  that  they  present  a  striking  picture  Montreal  Med.  ChronicU. 
of  life;  in  which  the  reduced  scale  aptly  serves  to  I 

BY  THE  SAME  AUTHOR. 

A   PRACTICAL   TREATISE    ON    DISEASES   OF  THE   SKIN.      Third 

American  edition.     In  one  neat  royal  12mo.  volume,  extra  cloth,  of  334  pages.     $1  00. 

t&^  The  two  volumes  will  be  sent  by  mail  on  receipt  of  Five  DoUan. 


OWKN   ON    THB   DIFFKRENT    FORMS    OF  I     One  vol.  royal  12mo.,  extra  cloth  with  numerouB 
THE  SKELETON,  AND   OF   THE   TEETH.  |     Ulusirations.    8125. 


PIRRIE(WILLIAM),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  .Aberdeen. 

THE    PRINCIPLES  AND  PRACTICE  OF  SURGERY.     Edited  by  John 

Nkill,  M.  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  tothe  Pennsylvania 
Hospital,  J^-c.  In  one  very  handsome  octavo  volume,  leather,  of  780  pages,  with  316  illustrations. 
$3  75.  . 

We  know  of  no  other  tnrgical  work  of  a  reason-  '  rately  diicossed  the  principles  of  surgery,  and  a 
able  size,  wherein  there  ii  somuch  Iheoryand  prac-  safe  and  effectual  practice  predicated  upon  them, 
tice,  or  where  subjects  are  more  soundly  or  clearly  Perhaps  no  work  upon  this  subject  heretofore  issued 
taught. —  The  Suthoicopt.  is  so  lull  upon  the  science  of  the  art  of  surgery. — 

Prof.  Pirric,  in  the  work  before  us,  has  elabo-    ^'<^i>ivilU  Journal  of  Medicine  and  Surgery . 


AND  SCIENTIFIC    PUBLICATIONS. 


25 


PARRISH   (EDWARD), 

Lecturer  on  Practical  Pharmacy  and  Materia  Medica  in  tlie  Pennsylvania  Academy  of  Medicine, 4c. 

AN  INTRODUCTION  TO  PRACTICAL  PHARMACY.    Designed  as  a  Text- 

Book  for  the  Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  For- 
mulae and  Prescriptions.  Second  edition,  greatly  enlarged  and  improved.  In  one  handsome 
octavo  volume  of  720  pages,  with  several  hundred  Illustrations,  extra  cloth.  $3  GO.  (iVuM> 
Rearlij.) 

During  the  short  time  in  which  this  work  has  been  before  the  profession,  it  has  been  received 
with  very  great  favor,  and  in  assuming  the  position  of  a  standard  authority,  it  has  filled  a  vacancy 
which  had  been  severely  felt.  Stimulated  by  this  encouragement,  the  author,  in  availing  himself 
of  the  opportunity  of  revision,  has  spared  no  pains  to  render  it  more  worthy  of  the  confidence  be- 
stowed upon  it,  and  his  assiduous  labors  have  made  it  raiher  a  new  book  than  a  new  edition,  many 
portions  having  l/een  rewritten,  and  much  new  and  important  matter  added.  These  alterations  and 
improvements  have  been  rendered  necessary  by  the  rapid  progress  made  by  pharmacenticral  science 
during  the  last  few  years,  and  by  the  additional  experience  obtained  in  the  practical  use  of  the 
volume  as  a  text-book  and  work  of  reference.  To  accommodate  these  improvements,  the  size  of 
the  page  has  been  materially  enlarged,  and  the  number  of  pages  c<insiderably  increased,  presenting 
in  all  nearly  on(-half  more  matter  than  the  last  edition.  The  work  is  therefore  now  presented  as  a 
complete  exponent  c)f  the  subject  in  its  most  advanced  condition.  From  the  most  ordinary  matters 
in  the  dispensing  otlice,  to  the  most  complicated  details  of  the  vegetable  alkaloids,  it  is  hoped  that 
everything  requisite  to  the  practising  physician,  and  to  the  apothecary,  will  be  found  fully  and 
clearly  set  forth,  and  that  the  new  matter  alone  will  be  worth  more  than  the  very  moderate  cost  of 
the  work  to  those  who  have  been  consulting  the  previous  edition. 

there  is  no  production  of  the  kind  in  the  Eng:lish 


That  Edward  Parrish,  in  writing  a  book  upon 
Xirattical  Pharmacy  some  few  years  ago — one  emi- 
nently original  and  unique — did  the  medical  and 
pharmaceutical  professions  a  great  and  valuable  ser- 
vice, no  one,  we  lluulc,  who  has  had  access  to  its 
pages  will  deny ;  doubly  welcome,  then,  is  this  new 
edition,  containing  the  added  results  of  his  recent 
and  rich  experience  as  an  observer,  teacher,  and 
practic  il  operator  in  the  pharmaceutical  laboratory. 
The  excellent  plan  of  the  first  is  more  thoroughly, 
and  in  detail,  carried  out  in  this  edition. — Peninsular 
Mid.  Journal,  Jan.  ISCO. 

We  know  of  no  work  on  the  subject  which  would 
be  more  indispensable  to  the  physician  or  student 
desiring  informaticmcm  the  subject  of  which  it  treats. 
With  Griffith's  "  Medical  Formulary"  and  this,  the 
practising  physician  would  be  supplied  with  nearly 
or  quite  all  the  most  useful  infonnation  on  the  sub- 
ject.— Ckarleslon  Med.  Journal  and  Review,  Jan. 
1&60. 

This  edition,  now  much  enlarged,  is  one  of  the 
most  useful  works  of  the  past  year. — N.  O.  Med. 
and  Surg.  Journal,  Jan.  1800. 

The  whole  treatise  is  eminently  practical;   and 


lansjuage  so  well  adupted  to  the  wants  of  the  phar- 
maceutist and  druga: ist.  To  physicians,  also,  it  can- 
not fail  to  be  highly  valuable,  especially  to  those 
who  are  oliliged  to  prepare  and  compound  many  of 
their  own  medicines. — iV.  Am.  Med.  Ckir.  Review, 
Jan.  ISGO. 

Of  course,  all  apothecaries  who  have  not  already 
a  copy  of  the  first  edition  will  procure  one  of  this; 
it  is,  therefore,  to  physicians  residing  in  the  country 
and  in  small  towns,  who  cannot  avail  themselves  of 
the  skill  of  an  educated  pharmaceutist,  that  we 
would  especially  commend  this  work.  In  it  they 
will  find  all  that  they  desire  to  know,  and  should 
know,  but  very  little  of  which  they  do  really  Know 
in  reference  to  this  important  collateral  branch  of 
their  profession;  for  it  is  a  well  established  fact, 
that,  in  the  education  of  physicians,  while  the  sci- 
ence of  medicine  is  generally  well  taught,  very 
little  attention  is  paid  to  the  art  of  preparing  them 
for  use,  and  we  know  not  how  this  defect  can  be  so 
well  remedied  as  by  procuring  and  consulting  Dr. 
Pairish's  excellent  work. — St.  Louis  Med.  Journal. 
Jan. ISGO. 


PEASLEE  (E.  R.),   M.  D., 

Professor  of  Physiology  and  General  Pathology  in  the  New  York  Medical  College. 

HUMAN  HISTOLOGY,  in  its  relations  to  Anatomy,  Physiology,  and  Pathology; 

for  the  use  of  Medical  Students.     With  four  hundred  and  thirty- four  illustrations.    In  one  hand- 
some octavo  volume,  of  over  600  pages.     (Lately  Published.)    $3  75. 

We  would  recommend  it  to  the  medical  student 


It  embraces  a  library  upon  the  topics  discussed 
within  itself,  andis  just  what  the  teacher  and  learner 
need.  Another  advantage,  by  no  means  to  be  over- 
looked, everything  of  real  value  in  the  wide  range 
which  it  embraces,  is  with  great  skill  compressed 
into  an  octavo  volume  of  but  little  more  than  si.x 
hundred  pages.  We  have  not  only  the  whole  sub- 
ject of  Histology,  interesting  in  itself,  ably  and  fully 


and  practitionerj  as  containing  a  summary  of  all  that 
is  known  of  tlie  important  subjects  which  it  treats ; 
of  all  that  is  contained  in  the  great  works  of  Simon 
and  Ijchinann,  and  the  organic  chemists  in  general. 
Master  this  (me  volume,  we  would  say  to  the  medical 
student  and  practitioner — master  tl.is  book  and  you 
know  all  that  is  known  of  the  great  fundamental 


discussed,  but  what  is  of  infinitely  greater  interest  j  principles  of  medicine,  and  we  have  no  hesitation 


to  the  student,  because  of  greater  practical  value, 
are  its  relations  to  Anatomy,  Physiology,  and  Pa- 
thology, which  are  here  fully  and  satisfactorily  set 
Unth..—  Naskville  Journ.  of  Med.  and  Surgery,  Dec. 
1357. 


n  saying  that  it  is  an  honor  to  the  American  medi- 
cal profession  that  one  of  its  members  should  have 
produced  it. — St.  Louis  Mid.  and  Surg.  Journal, 
March,  1853. 


PEREIRA  (JONATHAN),  M.  D.,  F.  R.  S.,  AND  L.  S. 
THE    ELEMENTS    OF   MATERIA    MEDICA    AND    THERAPEUTICS. 

Third  American  edition,  enlarged  and  improved  by  the  author;  including  Notices  of  most  of  the 
Medicinal  Substances  in  use  in  the  civilized  world,  and  forming  an  Encyclop«?dia  of  Materia 
Medica.  Edited,  with  Additions,  by  Joseph  Carson,  M.  D.,  Professor  of  Materia  Medica  and 
Pharmacy  in  the  University  of  Pennsylvania.  In  two  very  large  octavo  volumes  of  2100  pages, 
on  small  type,  with  about  500  illustrations  on  stone  and  wood,  strongly  bound  in  leather,  with 
raised  bands.  Sir*  00. 
1).*^  Vol.  II.  will  Qo  longer  be  sold  separate. 

PARKER  (LANGSTON), 

Surgeon  to  the  C^ueen's  Hospital,  Birmingham. 

THE  MODERN  TREATMENT  OF  SYPHILITIC  DISEASES,  BOTH  PRI- 
MARY AND  SECONDARY;  comnrisinglhe  Treatment  of  Constitutional  andConfirmed  Syphi- 
lis, by  a  safe  and  successful  methoti.  With  numerous  Cases,  Formulae,  and  Clinical  Observa- 
tions. From  the  Third  and  entirelv  rewritten  London  edition.  In  one  neat  octavo  volume, 
extra  cloth,  of  316  pages.    $175. 


26 


BLANCHARD    &    LEA'S    MEDICAL 


RAMSBOTHAM  (FRANCIS  H.),   M.D. 
THE  PRINCIPLES  AND  I'RACTICE  OF  OHSTETRIC  MEDICINE  AND 

SLFRlJKKY,  in  relereiice  to  tlie  Process*  o(  Parturition.  A  new  and  enlarged  edition,  thoroughly 
revi.'^'d  l»y  the  Author.  With  Additions  by  W.  V.  Keating,  M.  D.  In  one  large  and  handsome 
iniijerial  of luvo  volume,  ol>).')0  pagec,  ^trongly  bound  in  leather,  with  raised  bands;  with  sixty- 
four  beauiilul  Plates,  and  numerous  Wood-cuts  in  the  text,  containing  in  all  nearly  two  himdred 
large  and  beautiful  figures.    $.0  00. 

From  Prof.  Hod^$,  of  ike  University  of  Pa. 
To  the  American  public,  it  la  moBt  valiiiitile,  from  its  intrinsic  umlDuhted  excellence,  and  as  being 
the  belt  authorized  exponent  of  Britisli  Midwifery.    Its  circulation  will,  1  trust,  be  extensive  throughout 
oar  country. 

It  is  unneeesBnrv  to  siiy  anything  in  regard  to  the  i  truly  elegnnt  style  in  which  they  have  brought  it 
ntility  <»f  this  work.  It  i's already  u|iprfcmted  in  our  i  out,  excelling  themselves  in  its  production,  espe- 
couDtry  for  the  value  of  the  matter,  the  clearness  of  eiallv  in  its  plates.  It  is  dedicated  to  Prof.  Meigs, 
Its  style,  and  the  fulness  of  its  illustrations.  To  the  and  has  the  emphatic  endorsement  of  I'rof.  Hodge, 
physician's  library  it  Is  indispenKable,  while  to  the  as  the  best  exponent  of  British  Midwifery.  We 
student  as  a  ti-xt-book.  from  which  to  extract  the  knt.w  of  no  text-book  which  deserves  in  all  respects 
material  for  laying  the  foundation  of  an  education  on  '  to  he  more  highly  recommended  to  students,  and  we 
obstetrical  »ci.-nce,  it  has  no  superior.— OAio  JVfed  I  could  wish  to  see  it  in  the  handsof  every  practitioner, 
anti  Surg.  Journal.  I  for  they  will  find  it  invaluable  for  reference.— 3fed. 

The  publishers  have  secured  its   success  by  the  I  i****"*' 


RICORD  (P.),   M.  D. 

A  TREATISE  ON  THE  VENEREAL  DISEASE.     By  John  Hunter,  F.  R.  S. 

With  oojiious  Additions,  by  Ph.  Kicord,  M.  D.    Translated  and  Edited,  with  Notes,  by  Fref.mam 
J.  BiwsTF.AD.  M.  D  ,  Lecliirer  on  Venereal  at  the  College  of  Physicians  and  Surgeons,  New  York. 
Second  editiin,  revised,  coiilaining  a  re.-nime  of  Ricord's  Recent  Lectures  o.n  Chancre.     In 
one  handsome  octavo  volume,  extra  cloth,  or.'J50  pages,  with  eight  plates.    $3  25.    {Just  Issued.) 
In  revising  this  work,  the  editor  has  endeavored  to  introduce  whatever  matter  of  interest  the  re- 
cent inve>tigaiions  of  syphilographers  have  added  to  our  knowledge  of  the  subject.     The  principal 
Kource  from  which  this  has  been  derived  is  the  volume  of  "Lectures  on  Chancre,"  publi>lied  a  few 
months  since  by  M.  Ricord,  which  ntl'oids  a  large  amount  of  new  and  instructive  material  on  many 
controverted  pi>iiits.     In  the  previous  edition,  M.  Ricord's  additions  amounted  to  nearly  one-third 
of  the  whole,  and  with  the  mailer  now  introduced,  the  work  may  be  considered  topreseul  his  views 
nnd  experience  more  thoroughly  and  completely  than  any  other. 

oecretaries,  sometimes  accredited  and  sometimes  not. 
In  the  notes  10  Hunter,  the  master  subaiituies  him- 


Kvcry  one  will  recognize  llie  auracliveiicss  and 
Talue  which  this  work  derives  from  thus  pre.«eniiDg 
the  opinion"  of  these  two  masters  side  by  side.  Bui, 
It  must  I'O  admitted,  what  has  made  the  forlune  oi 
the  book,  is  ihe  fuel  lliai  it  coiiluius  ilie  "most  coni- 

flele  embodim^'iu  of  the  veriublc  doctrines  of  the 
lApital  du  Alidi,"  which  has  ever  been  made  public. 
The  doctrinal  id<'as  of  M.  Ricord.  ideas  which,  if  not 
universally  adopted,  aie  incorilesiably  dominant,  have 
heretofore  only  been  interpreted  by  more  or  lessskilful 


selfforhis  interpreters,  and  gives  hisoriginal  ihoufrhts 
to  ilie  world  in  a  lucid  and  perfectly  iiilrlliijiblc  man- 
ner. Ill  conclusion  we  can  say  thai  this  is  incon- 
lesiably  the  best  treaiise  on  syphilis  with  which  we 
are  acquainted,  and.  as  we  do  nol  ofieii  employ  the 
phrase,  wc  may  be  excused  lor  expressing  ilie  hope 
thai  it  may  find  a  place  in  the  library  of  every  phy- 
sician.—  Virginia  Mid.  and  Surg.  Journal. 


BY   THE  SAME   AUTHOR. 

RICORD'S  LETTERS  ON  SYPHILIS.   Translated  by  W.  P.  Lattimore,  M.  D. 

In  one  neat  octavo  volume,  of  270  pages,  extra  cloth.     $2  00. 


ROYLE'S   MATERIA   MEDICA   AND   THERAPEUTICS;   including  the 

Preparations  of  the  Pharmacopoeias  of  London,  Edinburgh,  Dublin,  and  of  the  United  btates. 
With  many  new  medicines.  Edited  by  Joseph  Carson,  M.  D.  With  ninety-eight  illustrations. 
In  one  large  octavo  volume,  extra  cloth,  of  about  700  pages.    S.'^  00. 


ROKITANSKY 

Curator  of  the  Imperial  Pathological  Museum, 

A    MANUAL   OF  PATHOLOGICAL 

bound  in  two.  extra  cloth,  of  nboiit  1200  pasres. 
KING,  C.  H.  Moore,  and  G.  E.  Day.  S-O  .10 
The  profession  is  too  well  acquainted  with  the  re- 
putation of  Rokitansky's  work  to  need  our  assur- 
ance that  this  is  one  of  the  most  profound,  thorough, 
and  valualile  books  ever  issued  from  the  medical 
press.  It  IS  .<Mi  g'ft<rt.«,  and  has  no  standard  of  com- 
parison. It  is  only  necessary  to  announce  that  it  is 
issued  inn  form  ns  cheap  as  is  coiiipatilile  with  its 
size  nnd  preservation,  and  its  sale  follows  as  a 
matter  of  course.  No  library  can  be  called  com- 
plete without  it. — Buffalo  Med.  Journal. 

Au  attempt  to  give  our  readers  any  adequate  idea 
of  the  vast  amount  of  instruction  accumulated  in 
these  volumes,  would  be  feeble  and  hopeless.  The 
cITort  of  the  distinguished  author  to  concentrate 
in  a  small  space  his  great  fund  of  knowledge,  has 


(CARL),    M.D., 

and  Proiessor  at  the  University  of  Vienna,  &C. 

ANATOMY.     Four  volumes,   octavo, 
Translated  by  W.  E.  Swaine,  Edward  Sikvb- 

80  charged  his  text  with  valuable  truths,  that  any 
attempt  of  a  reviewer  to  epitomize  is  at  once  para- 
lyzed, and  must  end  in  a  failure. —  Western  Lancet. 

As  this  is  the  highest  source  of  knowledge  upon 
the  important  subject  of  which  it  treats,  no  real 
student  can  afford  to  be  without  it.  The  American 
publishers  have  entitled  themselves  to  the  thanks  of 
the  profession  of  their  country,  for  this  tiiiieousand 
beautiful  edition. — I\'a.'ihville  Journal  of  Medicim. 

Asa  book  of  reference, therefore,  this  work  must 
prove  of  inestimable  value,  and  we  cannot  loo  highly 
recommend  it  to  the  profession. — Charleston  Med. 
Journal  and  Heview. 

This  book  is  a  necessity  to  every  practitioner. — 
Am.  Med.  Monthly. 


RIGBY    (EDWARD),    M.  D., 

Senior  PhvHician  to  tlie  IJeneral  Lving-in  Hospital,  ice. 

A    SYSTEM    OF    .MiinVlFERY.     With  Notes  and  Additional  Illustrations. 

Second  American  Edition.     One  volume  octavo,  extra  cloth,  422  pages.     $2  50. 
BY  the  same  author.     [Lately  Publishfii.) 

ON  THE  CONSTITUTIONAL  TREATMENT  OF  FEMALE  DISEASES. 

In  one  neat  royal  12mo.  volume,  extra  cloth,  of  alx)ut  250  pages.    $1  00, 


AND    SCIENTIFIC    PUBLICATIONS.  27 

STILLE  (ALFRED),    M.D. 
THERAPEUTICS  AND  MATERIA  MEDICA ;  a  Systematic  Treatise  on  the 

Action,  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History.     In  two  large  and 

handsome  octavo  volumes,  of  17S9  pages.     (Now  Ready,  ISdO.)     $S  00. 

This  work  is  designed  especially  for  the  student  and  practitioner  of  medicine,  and  treats  the  various 
articles  of  the  Materia  Medica  from  the  point  of  view  of  the  bedside,  and  not  ol  the  shop  or  of  the 
lecture-room.  While  thus  endeavoring  to  give  all  practical  informaiion  likely  to  be  useful  with 
respect  lo  the  employment  of  special  remedies  in  special  affections,  and  the  results  to  be  anticipated 
from  their  administration,  a  copious  Index  of  Diseases  and  their  Kemedies  renders  the  work  emi- 
nently titled  lor  reference  by  showing  at  a  glance  ihe  ditVerent  means  which  have  been  employed, 
and  enabling  the  practitioner  to  e.xiend  his  resources  in  ditlicull  ca-es  with  ail  that  the  experience 
of  the  prole-^sion  has  suggested.  At  the  same  time  panicular  care  has  been  given  to  the  subject 
of  General  Therapeutics,  and  at  the  commencement  of  each  class  of  medicines  there  is  a  chapter 
devoted  lo  the  consideration  of  their  common  indtience  upon  morbid  conditions.  The  action  of 
remedial  aiients  upon  the  healthy  economy  and  on  animals  has  likewise  received  particular  notice, 
from  the  ci  iiviction  that  their  physiological  ellects  will  afford  frequent  explanations  of  iheir  patho- 
logical inlluence.  and  in  many  ca>es  lead  lo  new  and  important  suggestions  a,-  to  their  practical  use 
in  disease.  Within  the  scope  thus  designed  by  the  auihor,  no  labor  has  been  spared  lo  accumulate 
all  the  facts  which  have  accrued  from  the  experience  of  the  profession  in  all  airt^s  and  all  countries  ; 
and  the  vast  amoimt  of  recent  re^earches  recorded  in  the  periodical  literature  of  both  hemispheres 
has  been  zealously  laid  under  contribution,  resulting  in  a  mass  of  practical  iafonnatioii  scarcely 
attempted  hulierto  in  any  similar  work  in  the  language. 

Our  expectations  of  the  value  of  this  work  were  the  practical  utility  of  his  book  by  passin;;  briefly 
based  on  the  well-known  reputalion  and  cliaracter  over  the  physical,  botani 'al,  aiid  ennnnercial  history 
of  the  author  as  a  man  of  scholarly  attainments,  an  nf  medicines,  and  direciiiig  attention  ehitfly  to  their 
elegant  writer,  a  candid  inquirer  after  truth,  and  a  physiological  action,  and  their  application  for  the 
philosophical  thinker ;  we  knew  that  the  task  would  amelioration  or  cure  of  disease.  He  igrnores  hypothe- 
be  conseieiitinusly  performed,  and  that  few,  if  any,  sie  and  theory  which  are  so  alluring  to  many  medical 
ainoD^  the  distinguished  medical  teachers  in  this  writers,  and  so  liable  to  lead  them  astray,  and  con- 
counlry  are  Ijettcr  qualified  than  he  to  prepare  a  fines  himself  to  such  facts  as  have  been  tried  in  the 
systeaatic  treatise  on  therapeutics  in  aecnrdance  crucible  of  experience. — Chicago  Medical  Journal, 
with  the  present  requirements  of  medical  science,  i  March,  ISOO. 

Our  priliminary  examination  of  the  work  has  satis-  ,  The  plan  pursued  by  the  author  in  these  veryela- 
fied  us  that  we  were  not  mistaken  in  our  anticipi-  borate  volumes  is  not  strictly  one  of  scientific  unity 
li.ms.  In  cmjratulating  the  au-hor  on  the  comple-  (j^j  precision  ;  he  has  rather  subordinated  these  to 
tion  of  the  great  labor  which  such  a  work  involves,  |  practical  utility.  Ur.  Stille  has  produced  a  work 
we  are  happy  in  expressing  the  conviction  that  its  ,  which  will  be  valuable  equally  to  the  student  of 
merits  will  receive  that  rew.ard  which  is  above  all  medicine  and  the  busy  practitioner. -i-o/iioTi  Lan- 
price—  the  grateful  apprtciation  of  his  medical  bre-     jjj   Alarch  10    1S60. 

thren.— Ntw  Orleans  Medical  News,  M&TCh,  ISOO.  ,',r-.u  ti      •'      n'     i-  i\t-.  in        Aitr     ju 

'  '  I      Wilh  Pereira,  Dunglison,  Mitchell,  and  Wood  be- 

We  think  this  work  will  do  much  to  obviate  the  j  fore  us,  we  may  well  ask  if  there  was  a  necessity 
reluctance  to  a  thorough  investigation  of  this  branch  ,  for  a  new  book  on  the  subject.  After  examining  this 
of  scientific  study,  for  in  the  wide  range  of  medical  '  work  with  some  care,  we  can  answer  affirmatively, 
literature  treasured  in  the  English  t(mgue,  we  shall  [  Dr.  Wood's  book  is  well  adapted  for  students,  while 
hardly  find  a  work  written  in  a  style  more  cle.ir  and  j  J)r.  StiUe's  will  be  more  sitisfacfory  to  the  practi- 
simple,  cuDVpying  forcibly  the  facts  taught,  and  yet  \  tioner,  who  desires  to  study  the  action  of  medicines, 
t'ree  from  tursridiiy  and  redundancy.  There  isa  fas- i  The  author  needs  no  encomiums  from  us,  ("or  he  is 
cination  in  its  pages  that  will  insure  to  it  a  wide  |  well  known  as  a  ripe  scholar  and  a  man  of  the  most 
popularity  and  attentive  perusal,  and  a  degree  of  ^  extensive  reading  in  his  profession.  This  work  bears 
usefulnets  not  often  attained  through  the  influence'  evidence  of  this  fact  on  every  page. — Cincinnati 
of  a  single  work.     The  author  has  much  enhanced  i  Lancet,  April,  IsOO. 


SMITH    (HENRY    H.),   M.D. 
MINOR  SURGERY;  or,  Hints  on  the  E very-day  Duties  of  the  Surgeon.     With 

247  illustrations.    Third  edition.    1  vol.  royal  12ino.,  pp.  456.    In  leather,  $2  2-5;  cloth,  $2  00. 

BY   THE  SAME   AUTHOR,   AND 

HORNER  (WILLIAM  E.),   M.D., 
Late  Professor  of  Anatomy  in  the  University  of  Pennsylvania. 

AN  ANATOMICAL  ATLAS,  illustrative  of  the  Structure  of  the  Human  Body. 
In  one  volume,  large  imperial  octavo,  extra  cloth,  wilh  about  six  hundred  and  fifty  beautiful 
figures.     $3  00. 


These  figures  are  well  selected,  and  present  a 
complete  and  accurate  representation  of  that  won- 
derful fabric,  the  human  body.  The  plan  of  this 
Atlas,  which  renders  it  so  peculiarly  convenient 
for  the  student,  and  its  superb  artistical  execution, 
have  been  already  pointed  out.     We  must  congratu- 


late the  student  upon  the  completion  of  thisAtlaS] 
as  it  is  the  most  convenient  work  of  the  kind  that 
has  yet  appeared  ;  and  we  must  aiUI,  the  very  beau- 
tif^ul  manner  in  which  it  is  "  got  up"  is  so  creditable 
to  the  country  as  to  be  flattering  to  our  national 
pride. — ArTurican  Medical  Journal. 


SHARPEY  (WILLIAM),    M.  D.,   JONES   QUAIN,   M.  D.,   AND 

RICHARD  QUAIN,   F.  R.  S.,  &.c. 

HUMAN  ANATOMY.     Revised,  with  Notes  and  Additions,  by  Joseph  Letdt, 

M.  D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.  Complete  in  two  large  octavo 
volumes,  leather,  of  about  thirteen  hundred  pages.  Beautifully  illustrated  with  over  five  hundred 
engravings  on  wood.    $6  00. 

SIMPSON  (J.  Y.   ,   M.  D., 

Professor  of  Midwifery,  &e.,  in  the  University  of  Edinburgh,  Sec. 

CLINICAL  LECTURES  ON  THE  DISEASES  OF  FEMALES.     With  numo- 

rous  illustrations. 

This  valuable  series  of  practical  Lectures  is  now  appearing  in  the  "Medical  News  and 
Library"  for  1560,  and  can  thus  be  had  without  cost  by  subscribers  to  the  "American  Journal 
OF  THE  Medical  Sciences."    See  p.  2. 


28  BLANCHARD    &   L.EA'S3    MBUIUALi 


SARGENT  (F.  W.),  M.  D. 
ON  BAXDAGING  AND  OTHER  OPERATIONS  OF  MINOR  SURGERY. 

Second  edition,  enlarged.     One  handsome  royal  12mo.  vol.,  of  nearly  400  pages,  willi  182  wood- 
cuts.    Extra  cloth,  SI  40;  leather,  SI  50. 

Sareent's  Minor  s^urgpry  hue  always  been  popular,  I      A  work  that  has  been  so  long  and  favorably'  known 
and  deservedly  »o.  It  furnislies  that  knowledge  of  the  |  to  tlie  profession  ^as  Dr^  Sargcnt^s  Minor  tjurgery, 

must   f  "  ,  _    -.  .,_,  ~  ,..™  ..„  «,.,.,..   ,    ,„.».,. 

art  wli 


loe  cliDieal  lectures.  Tlie  art  of  bandaging,  which  I  dom  gets  that  attention  in  our  schools  tliat  its  im- 
is  regularly  UuRlit  in  Europe,  is  very  frequently  I  portance  deserves.  Our  larger  works  are  also  very 
overlooked  by  teachers  in  this  country  ;  the  student  defective  in  tlieir  teaching  on  these  siiuill  practical 
and  junior  pruclilioner,  therefore,  may  often  require  points.  This  little  book  will  supply  the  void  which 
that  knowledge  which  this  little  volume  so  tersely  all  must  feel  who  have  not  studied  its  pages.— TTeil- 
and  happily  supplies  —CAor/es«o«  Med.  Journ.  and    em  Lanctt,  xMarch,  lb56. 


'requently  requisite  performances  of  surgical  needs  no  commendation  from  us.  We  would  remark, 
lieh  cannot  be  entirely  understood  by  attend-  j  however,  in  this  connection,  that  minor  surgery  sel- 
ioical lectu 
ularly  taug 
Miked  by  ten 
inior  pructil 
nowledge  v 
happily  suppi 
iiavMio,  March,  lb36.  

SMITH   (W.   TYLER),  M.  D., 

PhysiciJUi  Accoucheur  to  St.  Mary's  Hospital,  See. 

ON   PARTURITION,   AND   THE   PRINCIPLES   AND   PRACTICE   OP 

OBSTETKICS.    In  one  royal  12mo.  volume,  extra  cloth,  of  400  pages.    $125. 

BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PATHOLOGY  AND  TREATMENT 

OF  LEUCOKKliCEA.     With  numerous  illu!«traiions.    In  one  very  handsome  octavo  volume, 
extra  cloth,  of  about  250  pages.     SI  50. 

SOI.LV  ON  THK  HU.MAN  BRAIN;  its  Structure,  |  handsome  octavo  volume,  extra  cloth,  of  overC50 
Physiology,  and  Diseases.  From  the  Sec<md  and  !  pages,  with  about  one  hundred  wood-cuts.  ?3  35. 
much  enluiged  London  edition.  In  one  octavo  !  giMoNS  GENKKAi.  PATHOLOGY,  as  conduc- 
volume,  extra  cloth,  of  500  pages,  with  120  wood-  I  j^e  ,„  the  Estabhsniiitnt  of  Rati.mal  Principles 
cuts.    9'i  00.  f(>r  the  prevention  ano  Cure  of  Disease.    In  one 

SKEY'S  OPERATIVE  SURGERY.    In  one  very  '      octavo  volume,  extra  cloth,  of  212  pages.    81  25. 


TODD  (R.   B.),   M.D.,    F.  R.  S.,   &.c. 
CLINICAL  LECTURES  ON  CERTAIN  DISEASES  OF  THE  URINARY 

ORGANS  AND  ON  DROPSIES.     In  one  octavo  volume,  2S4  pages.     $1  50. 
BY  THE  SAME  AUTHOR.     {Now  Ready.) 

CLINICAL  LECTURES  ON  CERTAIN  ACUTE  DISEASES.     In  one  neat 

octavo  volume,  of  320  pages,  extra  cloth.     SI  75. 

The  subjects  treated  in  this  volume  are — Rheu.matic  Fever,  Continued  Fever,  Erysipelas, 
Acute  Internal  Inflammation,  Py>e.mia,  Pneumonia,  and  the  Therapeutical  Action  of  Alco- 
hol. The  importance  of  these  matters  in  the  daily  practice  of  every  physician,  and  the  sound 
practical  nature  of  Dr.  Todd's  writings,  can  hardly  fail  lo  attract  to  this  work  the  general  attention 
that  it  merits. 


TANNER  (T.    HJ,    M.  D., 

Physician  to  the  Hospital  for  \Vomen,  &c, 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAGNOSIS. 

To  which    is  added  The  Code   of  Ethics   of   the  American    Medical  Association.     Second 
American  Edition.     In  oae  neat  volume,  small  12mo.,  extra  cloth,  S7j  cents. 

TAYLOR  (ALFRED  S.),  M.  D.,  F.  R.  S., 

Lecturer  on  .Medical  Jurisprudence  and  Chemistry  in  Guy's  Hospital. 

MEDICAL  JURISPRUDENCE.     Fourth  American  Edition.     With  Notes  and 

References  to  A  merican  Decisions,  by  Edward  Hartshorne,  M.  D.   In  one  large  octavo  volume, 
leather,  of  over  seven  hundred  pages.     S3  00. 

No  work  upon  the  subject  can  be  put  into  the  |      It  is  not  excess  of  praise  to  say  that  the  volume 
hands  of  students  either  of  law  or  medicine  which    before  us  is  the  very  best  treatise  extant  on  Medical 


will  engage  them  more  closely  or  profitably;  and 
none  couM  be  oflcred  to  the  busy  practitioner  ol 
either  calling,  for  the  purpose  of  casual  or  hasty 
reference,  that  would  be  more  likely  toalTord  the  aid 
desired.  We  tlicrcl'ore  recommend  it  as  the  best  and 
■afest  manual  for  daily  \xw.— American  Journal  oj 
Medical  Sciences. 


Jurisprudence.  In  saying  this,  we  do  not  wish  to 
be  understood  as  detracting  from  the  merits  of  the 
excellent  works  of  Beck, 'Ryan,  Traill,  Guy,  and 
others;  but  in  interest  and  value  we  think  it  must 
be  conceded  that  Taylor  is  superior  to  anything  that 
has  preceded  it. — iV.  IV.  Medical  and  Surg.  Journal. 


BY  THK  SAME  AtJTHOR.     (New  Edition,  ju^t  issued.) 

ON  POISONS,  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.     Second  American,  from  a  second  and  revised  London  edition.      In  one  large 

octavo  volume,  ol  755  pages,  leather.     $3  50. 

Since  the  first  appearance  of  this  work,  the  rapid  advance  of  Chemistry  has  introduced  into 
use  many  new  substances  which  may  become  fatal  through  accident  or  design  —  while  at  the 
same  time  il  has  likewise  designated  new  and  more  exact  modes  olcouiUeractinir  or  detecting  those 
previou>ly  treated  of.  Mr.  Taylor's  po>ition  as  the  leading  medical  juri>t  of  England,  has  during 
this  periud  conferred  on  him  extraordinary  advantages  in  acquiring  experience  on  these  subjects, 
nearly  all  cases  of  moment  being  referred  to  him  lor  examination,  as  an  exj^ert  whose  testimony 
iti  generally  accepted  as  (inal.  The  results  of  his  labors,  therefore,  as  gathered  together  in  this 
volume,  cureliilly  weighed  and  sil'ted.  and  presented  in  the  clear  and  intelligible  style  for  which 
he  IS  noted,  may  be  received  as  an  acknowledged  authority,  and  as  a  guide  to  be  Ibllowed  with 
implicit  cuufideuce. 


AND    SCIENTIFIC    PUBLICATIONS.  29 

TODD  (ROBERT  BENTLEY),  M.  D.,  F.  R.  S., 

Professor  of  Physiology  in  King's  College,  London ;  and 

WILLIAM  BOWMAN,  F.  R.  S., 

Demonstrator  of  Anatomy  in  King's  College,  London. 

THE  PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY  OF  MAN.    With 

about  three  hundred  large  and  beautiful  illustrations  on  wood.     Complete  in  one  large  octavo 

volume,  of  950  pages,  leather.     Price  $4  50. 

^^  Gentlemen  who  have  received  portions  of  this  work,  as  published  in  the  "  Medical  News 
AND  Library,"  can  now  complete  their  copies,  if  immediate  application  be  made.  It  will  be  fur- 
nished as  follows,  free  by  mail,  in  pa|ier  covers,  with  cloth  backs. 

Parts  I.,  II.,  III.  (pp.  25  to  502),  $2  50. 

Part  IV.  (pp.  553  to  end,  with  Title,  Preface,  Contents,  &c.),  $2  00. 

Or,  Part  IV.,  Section  II.  (pp.  725  to  end,  with  Title,  Preface,  Contents,  &c.),  $1  25. 


A  magnificent  contribution  to  British  medicine, 
and  the  American  pliysician  who  shall  fail  to  peruse 
it,  will  have  failed  to  read  one  of  the  most  instruc- 
tive books  of  the  nineteenth  century. — iV.  O.  Med 
and  Surg.  Journal,  Sept.  1857. 

It  is  more  concise  than  Carpenter's  Principles,  and 
more  modern  than  tlie  accessible  edition  of  .MQller's 
Elements;  its  details  are  brief,  but  sufhciert;  its 
descriptions  vivid  ;  its  illustrations  exact  and  copi- 
ous ;  and  its  language  terse  and  perspicuous. — 
Charleston  Med.  Journal,  July,  1857. 

We  know  of  no  work  on  the  subject  of  physiology 


so  well  adapted  to  the  wants  of  the  medical  student. 
Its  completion  has  been  thus  loni^  delayed,  that  the 
authors  might  secure  accuracy  by  personal  observa- 
tion.— St.  Louis  Med.  and  Surg.  Journal,  Sept.  '57. 

Our  notice,  though  it  conveys  but  a  very  feeble 
and  imperfect  idea  of  the  magnitude  and  importance 
of  the  work  now  under  consideration,  already  tran- 
scends our  limits  ;  and,  with  the  indulgence  of  our 
readers,  and  the  hope  that  they  will  peruse  the  book 
for  themselves,  as  we  feel  we  can  with  confidence 
recommend  it,  we  leave  it  in  tlieir  hands.  —  The 
Northteestern  Med.  and  Surg.  Journal. 


TOYNBEE  (JOSEPH),   F.  R.  S., 

Aural  Surgeon  to,  and  Lecturer  on  Surgery  at,  St.  Mary's  Hospital. 

A  PRACTICAL  TREATISE  ON  DISEASES   OF   THE   EAR;   their  Diag- 

nosis.  Pathology,  and  Treatment.     Illustrated  with  one  hundred  engravings  on  wood.    In  one 
very  handsome  octavo  volume,  extra  cloth,  $3  00.     {Now  Ready.) 

Mr.  Toyiil'ce's  name  is  too  widely  known  as  the  highest  authority  on  all  matters  connected  wilk 
Aural  Surgery  and  Medicine,  to  require  special  attention  to  be  called  to  anything  which  he  may 
communicate  to  the  profession  on  the  subject.  Twenty  years'  labor  devoted  to  the  present  work 
has  embodied  in  it  the  results  of  an  amount  of  experience  and  observation  which  perhaps  no  otlier 
living  practitioner  has  enjoyed.  It  therefore  cannot  fail  to  prove  a  complete  and  trui^tworthy  guide 
on  all  matters  connected  with  this  obscure  and  little  known  class  of  diseases,  which  so  frequently 
embarrass  the  general  practitioner. 

The  volume  will  be  found  thoroughly  illustrated  with  a  large  number  of  original  wood-engrav- 
ings, elucidating  the  pathology  of  the  organs  of  hearing,  instruments,  operations,  &c.,  and  in  every 
respect  it  is  one  of  the  handsomest  specimens  of  mechanical  execution  issued  from  the  American 
press. 

The  following  condensed  synopsis  of  the  contents  will  show  the  plan  adopted  by  the  author,  and 
the  completeness  with  which  all  departinents  of  the  subject  are  brought  under  consideration. 
CHAPTER  I.  Introduction — Mode  of  Investigation — Dissection.  I[.  The  External  Ear — Ana- 
tomy— Pathology — .Malformations  —  Diseases.  III.  The  External  Meatus  —  Its  Exploration. 
IV.  The  External  Meatus — Foreign  Bodies  and  Accumulations  of  Cerumen.  V.  The  External 
Meatus — The  Dermis  and  Its  Diseases.  VI.  The  External  Meatus — Polypi.  VII.  The  External 
Meatus — Tumors.  VIH.  The  Membrana  Tynipani — Structure  and  Functions.  IX.  The  Mem- 
brana  Tympani — Diseases.  X.  The  Membrana  Tympani — Diseases.  XL  The  En>tachiaa 
Tube — Obstructions.  XII.  The  Cavity  of  the  Tympanum — Anatomy — Pathology — Diseases. 
XIII.  The  Cavity  of  the  Tympanum— Di.>eases.  XIV.  The  Mastoid  Cells— Diseases.  XV. 
The  Diseases  of  the  Nervous  Apparatus  of  the  Ear,  producing  what  is  commonly  called  "  Nerv- 
ous Deafness."  XVI.  The  Diseases  of  the  Nervous  Apparatus,  continued.  XVII.  Malignant 
Disease  of  the  Ear.  XVIII.  On  the  Deaf  and  Dumb.  XIX.  Ear-Trumpets  and  their  uses. 
Appe.ndix. 

WILLIAMS  (C.   J.   B.),    M.D.,    F.  R.  S., 

Professor  of  Clinical  Medicine  in  University  College,  London,  tea. 

PRINCIPLES  OF  MEDICINE.     An  Eleineataiy  View  of  the  Causes,  Nature, 

Treatment,  Diagnoses,  and  Prognosis  of  Disease;  with  briet  remarks  on  Hygienics,  or  the  pre- 
servation of  health.    A  new  American,  from  the  third  and  revised  London  edition.     In  one  octavo 
volume,  leather,  of  about  500  pages.     S2  50.     (Just  Issued.) 
We  find  that  the  deeply-interesting  matter  and  i  expressed.    It  is  a  judgment  of  almost  unqualified 


style  of  this  book  have  so  far  fascinated  us,  that  we 
have  unconsciously  hung  upon  its  pages,  not  too 
long,  indeed,  for  our  own  profit,  but  longer  than  re- 
viewers can  be  permitted  to  indulge.  We  leave  the 
furtheranalysis  to  the  student  and  practitioner.  Our 
Judgment  ot  the  work  has  already  been  sufficiently 


praise. — London  Lancet. 

A  text-book  to  which  no  other  in  our  language  is 
comparable. — Charleston  Medical  Journal. 

No  w^ork  has  ever  achieved  or  maintained  a  more 
deserved  reputation. —  Va.  M(d.  and  Surg.  Journal. 


WHAT   TO   OBSERVE 
AT    THE    BEDSIDE    AND    AFTER   DEATH,   IN    MEDICAL   CASES. 

Publishediindertheauthority  of  the  London  Society  for  Medical  Observation.    A  new  American, 

from  the  second  and  revised  Londoi.  edition.     In  one  very  handsome  volume,  royal  12mo.,  extra 

doth.    $1  00. 

To  the  observer  who  prefers  accuracy  to  blunders  I  One  of  the  finest  aids  to  a  yonng  practitioner  we 
and  precision  to  carelessness,  this  little  book  is  in-  have  ever  seen. — Peninsular  Journal  of  Mtdieint. 
valuable. — iV.  II.  Journal  of  Medic m*.  I 


30  BLANCHARD   b   LEA'S    MEDICAL 

New  and  much  enlarged  edition— (Just  Issued.) 

WATSON   (THOMAS),    M.  D.,    Sec, 
Lute  I'liysician  tn  the  Middlesex  Hospital,  iic. 

LECTURES    ON    THE    PRINCIPLES    AND    PRACTICE   OF   PHYSIC. 

Delivered  at  King's  Colleee,  London.     A  new  American,  from  the  las-t  revised  and  enlarged 

Enffli^'h  edition,  with  Additions,  by  D.  Francis  Co.ndie,  M.  D.,  author  of  "A  Praciical  Treatise 

on  the  Di>eu*es  olC'hildren,"  ice.     With  one  hundred  and  eighty. five  illustrations  on  wood.     In 

one  very  large  and  handsome  volume,  imperial  octavo,  of  over  1200  closely  printed  pages  in 

email  type;  the  whole  strongly  bound  in  leather,  with  raised  bands.     Price  $4  Qf). 

That  the  high  reputation  of  this  work  might  be  fully  maintained,  the  author  has  subjected  it  to  a 

ihorouKh  revision;  every  portion  has  been  examined  wiih  the  aid  of  the  most  recent  researches 

in   pathology,  and  the  results  of  modern  investigations  in  both  Iheore'.ical  and  practical  subjects 

have  f»een  carefully  weighed  and  embodied  throughout  its  pages.     The  watchful  scrutiny  of  the 

editor  has  likewise  introduced  whatever  possesses  immediate  importance  to  the  American  physician 

in  relation  to  diseases  incident  to  our  climate  which  are  little  known  in  England,  as  well  as  those 

points  in  which  experience  here  has  led  lodilferent  modesof  practice ;  and  he  has  also  added  largely 

to  the  series  of  illu>trations,  believing  that  in  this  manner  valuable  assistance  may  be  conveyed  to 

the  student  in  elucidating  the  text.     The  work  will,  therefore,  l)e  found  thoroughly  on  a  level  with 

the  most  advanced  state  of  medical  science  on  both  sides  of  the  Atlantic. 

The  additions  which  the  work  has  received  are  shown  by  the  (act  that  notwithstanding  an  en- 
largement in  the  size  of  the  pagp,  more  than  two  hundred  additional  pages  have  l>een  necessary 
to  accommodate  the  two  large  volumes  of  the  London  edition  (which  sells  at  ten  dollars),  within 
the  compass  of  a  single  volume,  and  in  its  present  form  it  contains  the  matter  of  at  lea<t  three 
ordinary  octavos,  l^elievina  it  to  be  a  work  which  should  lie  on  the  table  of  every  physician,  and 
be  in  the  hands  of  every  student,  the  publishers  have  put  it  at  aprice  within  the  reach  of  all,  making 
it  one  of  the  cheapest  books  as  yet  presented  to  the  American  profession,  while  at  the  same  time 
the  beauty  ot  its  mechanical  execution  renders  it  an  exceedingly  attractive  volume. 

The  fourth  edition  now  appears,  so  carefully  re-  The  lecturer's  skill,  his  wisdom,  his  learning,  are 
vised,  as  to  add  eonsideniljiy  to  the  value  of  a  book  equalled  by  the  ease  of  his  graceful  diction,  his  elo- 
already  acknowledged,  wherever  the  English  Ian-  quenee,  and  the  far  higher  qualities  of  candor,  of 
guage  is  read,  to  be  beyond  all  comparison  the  best  courtesy,  o(  modesty,  and  of  generous  appreciation 
8>Btematic  work  on  tlie  Principles  and  Practice  of  of  merit  in  others.  Mny  le  lo'ug  remain  to  instruct 
Physic  in  the  whole  range  of  medical  literature,  us,  and  to  enjoy,  in  the  glorious  sunset  of  his  de- 
Every  lecture  contains  proof  of  the  e.xlreme  anxiety  dining  years,  the  honors,  the  confidence  and  love 
of  the  author  to  keep  pace  with 'he  advancing  know-  gained  during  his  useful  life.— iV.  A.  Med-Chir. 
ledge  of  the  day,  and  to  bring  the  results  of  the    Reviete,  July,  ISSti. 

labors,  not  only  of  physicians,  but  of  chemists  and        ,,.  ,  •      .,   j  ,_  t   u, 

histologists,  before  his  readers,  wherever  they  can  Watson's  unrivalled,  perhaps  unapproachable 
be  turned  to  useful  account.  And  this  is  done  with  work  on  Practice-the  copious  adduions  made  to 
such  a  cordial  appreciation  of  the  merit  due  to  the  which  (the  fourth  edition)  have  given  it  all  the  no- 
industrious  .)b8erver,  such  a  generous  desire  to  en-  v^lty  and  much  of  the  interest  o|  a  new  book.— 
courage  younger  and  rising  men,  and  such  a  candid  Charleston  Med.  Journal,  July,  165... 
acknowledgment  of  his  own  obligations  to  them.  Lecturers,  practitioners,  and  students  of  medicine 
that  one  scarcely  knows  whether  to  admire  most  the  ^yjn  equally  hail  the  reappearance  of  the  work  of 
pure,  simple,  forcible  English— the  vast  amount  of  Dr.  Watson  in  the  form  of  a  new— a  fourth— edition, 
useful  practical  intormati<m  condensed  into  the  \Ve  merely  do  justice  to  our  own  feelings,  and,  we 
Lectures— or  the  manly,  kind-htarted,  unassuming  are  sure,  of  the  whole  profession,  if  we  thank  him 
character  of  the  lecturer  shining  thr.mgh  his  work.  (,„  having,  in  the  trouble  and  turmoil  of  a  large 
—London  Med.  Times  and  Gazette,  Oct.  31,  1857.  1  practice,  made  leisure  to  supply  the  hiatus  caused 
Thus  these  admirable  volumes  come  before  the  !  by  the  exhaustion  of  the  puiilislier's  stock  of  the 
professit>n  in  their  fourth  eiliiion,abfmnding  in  those  third  edition,  which  has  been  severely  felt  for  the 
distinguished  attributes  of  moderation,  judgment,  last  three  years.  For  Dr.  Watson  has  not  merely 
erudite  cultivation,  clearness,  and  eloquence,  with  caused  the  lectures  to  be  reprinted,  but  scattered 
which  they  were  from  the  first  invested,  but  yet  [  through  the  whole  work  we  find  additions  or  altera- 
richer  than  before  in  the  results  of  more  prolonged  tions  which  prove  that  the  author  has  in  every  way 
observation,  and  in  the  alile  appreciation  of  the  ]  sought  to  bring  up  his  teaching  to  the  level  of  th« 
latest  advances  in  pathology  and  medicine  by  one  j  most  recent  acquisitions  in  science. — Brit,  and  For. 
of  the  most  profound  medical  thinkers  of  the  day. —  Medieo-Chir.  Hevieui,  Jan.  165S. 
London  Lancet,  Nov.  14,  1857.  | 


WALSHE  (W.    H.),   M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London,  ie. 

A  PRACTICAL  TUKATISE  ON  DI-JEASES  OF  THE  LUNGS;  including 

the  Principles  of  Physical  Diagnosis.  A  new  American,  from  the  third  revised  and  much  en- 
larged London  edition.  In  one  vol.  octavo,  of  4b8  pages.  {Just  Issued,  June,  1860.)  §2  25. 
The  present  edition  hns  been  carefully  revised  and  much  enlarged,  and  may  be  said  in  the  main 
to  be  rewritten.  Descriptions  of  several  diseases,  previously  omitted,  are  now  iiitrixluced ;  the 
causes  and  mode  of  produc-tion  of  the  more  important  allcclions,  so  far  as  they  possess  direct  prac- 
tical significance,  are  succinctly  inquired  into;  an  effort  has  been  made  to  bring  the  description  ol 
anatomical  characters  lo  the  level  of  the  wants  of  the  practical  physician ;  and  the  diagnosis  and 
prognosis  of  each  complaint  are  more  completely  considered.  The  sections  on  Treat.mext  and 
the  Appendix  (conceriiiiig  ilic  intluence  of  climate  on  pulmonary  disorders),  have,  especially,  been 
largely  extended. — Aiit/ior's  Preface. 

0,*^  To  be  followed  by  a  similar  volume  on  Diseases  of  the  Heart  and  Aorta. 


WILSON  (ERASMUS),   F.  R.  S., 

Lecturer  on  Anatomy,  London. 

THE    DISSECTOR'S  MANUAL;  or,  Practical  and  Surgical  Anatomy.     Third 

American,  from  the  last  revised  and  enlarged  Engli^h  edition.  Modified  and  rearranged,  by 
William  Hunt,  M.  D.,  Demonstrator  of  Anatomy  in  the  University  ol  Pennsylvania.  In  one 
large  and  handsome  royal  12mo.  volume,  leather,  of  582  pages,  with  154  illustrations.     $2  00. 


AND    SCIENTIFIC    PUBLICATIONS  31 

Ne'w  and  much  enlarged  edition — (Just  Issued.) 

WILSON    (ERASMUS),  F.  R.  S. 

A  SYSTEM  OF  HUiMAN  ANATOMY,  General  and  Special.     A  new  and  re- 

vined  American.  frt)m  the  last  and  enlarged  Eiigli>h  Edition.    Edited  by  W.  II.  Gobkkcht,  M.  D. 

Professor  of"  Anatomy  in  the  Pennsylvania  Medical  College,  &:c.     lllnstrated  witli  liiree  hundred 

and  ninety-seven  engravings  on  wood.     In  one  large  and  exquisitely  printed  octavo  volume,  ol 

over  600  large  pages;  leather.     $3  25. 

The  publishers  trust  that  the  well  earned  reputation  so  long  enjoyed  by  this  work  will  l)e  more 
than  maintained  by  the  present  edition.  Besides  a  very  thorough  revision  by  the  author,  it  has  been 
most  carefully  examined  by  the  editor,  and  the  elTorts  of  both  have  been  directed  to  introducing 
everything  which  increased  experience  in  its  ii>e  has  suggested  as  desirable  to  render  it  a  complete 
text-book  tor  those  seeking  to  obtain  or  to  renew  an  acquaintance  with  Human  Anatomy.  The 
amount  of  additions  wliich  it  has  thus  received  may  be  estimated  from  the  (iict  that  the  present 
edition  contains  over  one-fourth  more  matter  than  the  last,  rendering  a  smaller  type  and  anenlar^'ed 
page  requisite  to  keep  the  volume  within  a  convenient  size.  The  author  has  not  only  thus  added 
largely  to  the  work,  but  he  has  also  made  alterations  throughout,  wherever  there  appeared  the 
opportunity  of  improving  the  arrangement  or  style,  so  as  to  present  every  fact  in  its  most  appro- 
priate manner,  and  to  render  the  whole  as  clear  and  intelligible  as  possible.  The  editor  has 
exercised  the  utmost  caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  increased  the 
number  of  illustrations,  of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition  than 
in  the  last,  thus  bringing  di>tinctly  before  theeye  of  the  student  everything  of  interest  or  imjiortance. 

It  may  be  recoininencled  to  the  student  as  no  less  ,  beauty  of  its  mecliiinical  execution,  and  the  clear- 
distinguished  by  its  accuracy  and  clearness  of  de-  ness  of  tlie  descriptions  whidi  it  contains  is  equally 
scriptnm  tli;in  by  its  typograpliical  elegance.  The  evident,  l^et,  students,  by  all  means  examuie  the 
wood-cuts  are  exquisite. — Brit,  and  For.  Medical  claims  of  this  work  on  their  notice,  bel'ure  theypur- 
""■""'"""  chase  a  text-book  of  the  vitally  important  science 

which  this  volume  so  fully  and  easily  unfolds. 

Lancet. 


Review. 

An  elegant  edition  of  one  of  the  most  useful  and 
accurate  systems  of  anatomical  science  which  has 
been  issued  from  the  press  The  illustrations  are 
really  beautil'ul.  In  its  style  the  work  is  extremely 
concise  and  intelligible.     No  one  can  possibly  take 


We  regard  it  as  the  best  system  now  extant  for 
students. — Western  Lancet. 

It  therefore  receives  our  highest  commendation. 


up  this  Volume  without  being  struck  with  the  great  ]  Southern  Med.  and  Surg.  Journal. 
BY  THE  SAME  AUTHOR.     (Just  Issued.) 

ON  DISEASES  OF  TPIE  SKIN.     Fourth  and  enlarged  American,  from  the  last 

and  improved  London  edition.     In  one  large  octavo  volume,  of  650  pages,  extra  cloth,  $2  75. 

The  writings  of  Wilson,  upondiseases  of  the  skin,  l  at  some  of  the  more  salient  points  with  which  it 
are  by  fir  the  most  scientific  and  practical  that  abounds, and  which  makeilincomparaurysupcriorin 
have  ever  been  prcsent«'d  to  the  medical  world  on  excellence  to  all  other  treatises<ni  the  subjectofder- 
this  subject.  The  present  edition  isa  great  improve-  matology.  No  mere  speculative  views  are  allowed 
meut  on  all  its  predecessors.  To  dwell  upon  all  the  a  place  in  this  volume,  which,  without  a  doubt,  will 
great  merits  and  high  claims  of  the  work  before  us,  for  a  very  long  period,  be  acknowledged  as  the  chief 
jer/affOT,  would  indeed  be  an  agreeable  service ;  it  standard  work  on  dermatology.  The  princii)les  of 
would  be  a  mental  homage  which  we  could  freely  an  enlightened  and  rational  therapeia  are  introduced 
ofTer,  but  we  should  thus  occupy  an  undue  amount  on  every  appropriate  occasion. — Am.  Jour.  Med. 
of  space  in  this  Jo«r»a/.    We  will,  however,  look     Science,  Oct.  1857. 

ALSO,  NOW  READY, 

A  SERIES  OF  PLATES  ILLUSTRATING  WILSON  ON  DISEASES   OF 

THE  SKIN  ;  consisting  of  nineteen  beautifully  executed  plates,  of  which  twelve  are  exquisitely 
colored,  presenting  the  Normal  AnaU)my  and  Pathology  of  the  Skin,  and  containing  accurate  re- 
presentations of  about  one  hundred  varieties  of  disease,  most  of  them  the  size  of  nature.     Price 
in  cloth  S-l  "-5. 
In  beauty  of  drawing  and  accuracy  and  finish  of  coloring  these  plates  will  be  found  equal  to 

anything  ol'  the  kind  as  yet  issued  in  this  country. 

The  plates  by  which  this  edition  is  accompanied  .      We  have  already  expressed  our  high  appreciation 

leave  nothing  to  be  desired,  so  far  as  excellence  of    of  Mr.  Wilson's  ireatise  <m  Diseases  of  the  Skin. 

delineation  and  perfect  accuracy  of  illustration  are    The   plates  are  comprised   in   a  sejiarate  volume 

concerned. — Medico-Ckirursiical  Hei-icw.  which  we  counsel  all  those  who  possess  the  text  to 

Of  these  plates  it  is  impossible  to  speak  loo  highly      purchase.     It  is  a  beautiful  tpecimen  of  color  prinl- 

The  representatiims  of  the  various  forms  of  cutane-     "'n  i  »"J  'he  representations  ol  the  various  forms  of 


skin  disease  an- iis  laithful  as  is  possible  in  jilates 
of  the  Bize.—Hoston  Med.  and  Surg.  Journal.  April 
S,  185«. 


I 


ous  disease  are  singularly  accurate,  and  ilie  color- 
ing exceeds  almost  anything  we  have  met  with  in 
point  of  delicacy  and  finish.— .Brjtii/i  anrf  Foreign 
Medical  Review. 

BY  THE  SAME   AUTHOR. 

ON    CONSTITUTIONAL    AND    HEREDITARY    SYPHILIS,   AND    ON 

SYPHILITIC  ERUPTIONS.     In  one  small  octavo  volume,  extra  cloth,  beautifully  printed,  with 
four  exquisite  colored  plates,  presenting  more  than  thirty  varieties  of  syphilitic  eruptions.  »2  25. 

BY   THE   SAME   AUTHOR. 

HEALTHY  SKIN;  A  Popular  Treatise  on  the  Skin  and  Hair,  their  Preserva- 
tion and  Management.  Second  American,  from  the  fourth  London  edition.  One  neat  volume, 
royal  12uio.,  extra  cloth,  of  about  300  pages,  with  numerous  illustrations.  £1  00;  pajn^r  cover, 
75  cents. 


VVHITKHK.XDON  THE  CAUSES  AND  TREAT-  I      Second  American  Edition.    In  one  volume,  octa- 
MENT   OF    ABORTION    AND   STERILITY.  I      vo  extra  cloth,  pp.  308.     «1    75. 


32  BLANCH^RD   &   LEA'S    MEDICAL  PUBLICATIONS. 


WINSLOW    (FORBES),   M.D.,    D.  C.  L.,   &.c. 
ON  OBSCURE  J)ISKA.SES  UF  TIJE  IJllAIN  AND  DISORDERS  OF  THE 

MIND;  their  inci|)ifiit  Symptoms,  Pathology,  Diagnosis,  Treatment,  and  Prophylaxis.  In  one 
hniid>oine  octavo  volume,  oC  nearly  GOO  pages.  {Just  Issued,  June,  IMJQ.)  §3  GO. 
The  momentous  questions  discussed  in  this  volume  have  perhaps  not  hitherto  been  so  ably  and 
elaboralelv  treated.  Dr.  Winslow's  distinguished  reputation  and  long  experience  in  everything  re- 
lating to  insanity  invent  his  teachings  with  the  highest  authority,  and  in. this  carel"ully  considered 
volume  he  has  drawn  upon  the  accumulated  resources  of  a  life  ol"  observation.  His  deductions 
are  lounded  on  a  vast  number  of  cases,  the  peculiarities  of  which  are  relaied  in  detail,  rendering 
tlie  work  not  only  one  ol  sound  in^truction,  but  of  lively  interest;  the  author's  main  object  l)eing 
to  point  out  the  connection  between  organic  disease  and  insanity,  tracing  the  laiter  through  all  its 
blages  Iroiu  mere  eccentricity  to  mania,  and  urging  the  necessity  of  early  measures  of  prophylaxis 
and  u|>iiropriute  treatment.  A  subject  of  greater  importance  to  society  at  large  could  scarcely  be 
named ;  while  to  the  physician  who  may  at  any  moment  be  culled  upon  for  interference  in  the  most 
delicate  relations  of  life,  or  for  an  opinion  in  a  court  of  justice,  a  work  like  the  present  may  be  con- 
sidered indisjieusable. 

The  treatment  of  the  subject  may  be  gathered  from  the  following  summary  of  the  contents  : — 
Chapter  I.  Introduction. — II.  Morbid  Phenomena  of  Intelligence.  III.  Premonitory  Symptoms 
of  Insanity- — IV.  Confessions  of  Patients  after  Recovery. — V.  Stale  of  the  Mind  during  Re- 
covery.— Vl.  Anomalous  and  Masked  Affections  of  tlie  i\lind. — VII.  The  Stage  o(  Coii.-eiousness. 
— Vlll.  Stage  of  Exaltation. — IX.  Stage  of  Mental  Depression. — X.  Siage  of  Aberration. — XI. 
Impaifmcnt  of  Mind. — Xil.  Morbid  I'henomena  of  Attention. — XIII.  Morbid  Plienomena  of 
Memory  — XIV.  Acute  Disorders  of  Memory. — W.  Chronic  Affections  of  Memory. — XVI. 
I'erversion  and  lOxaltalion  of  Memory. — XVII.  Psychology  and  Palholcgy  of  ileinory — XVIII. 
Morbid  I'henomena  of  Motion. — XIX.  ISIorbid  Phenomena  ol  Speech. — XX.  Morbid  Phenomena 
of  Sensation. — XXI.  iMorbid  Phenomena  of  the  Special  Senses. — XXII.  Morbid  Phenomena  of 
Vision.  Hearing,  Taste,  Touch,  and  Smell. — XXIII.  Morbid  Phenomena  of  Sleep  and  Dreaming. 
— XXIV.  Morbid  Phenomena  of  Organic  and  Nutritive  Life. — XXV.  General  I'rinciples  of  Pa- 
thology, Diagnosis,  Treatment,  and  Prophylaxis. 

WEST   (CHARLES),    M.  D., 

Accoucheur  to  and  Lecturer  on  Midwifery  at  :»t.  Biirtlmlomcw's  Hospital,  Physician  to  the  Hospital  for 

Sick  Chililreii,&c. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     Now  complete  iu  one  hand- 
some octavo  volume,  extra  cloth,  of  about  500  pages;  price  $2  50. 

Also,  for  sale  separate,  Part  II,  being  pp.  809  to  end,  with  Index,  Title  matter, 

(See,  Svo.,  cloth,  price  $1. 


and  children  is  not  to  be  found  in  any  country. — 
Southern  Merl.  and  Svrg.  Journal,  January  ISSe*. 

We  gladly  recommend  his  Lectures  as  in  the  high- 
est degree  instructive  to  all  wtio  are  iuterestcd  in 
obstetric  practice. — London  Lancet. 

We  have  to  say  of  it,  briefly  and  decidedly,  that 
it  is  the  best  work  on  the  sutjject  in  any  language; 
and  that  it  stamps  Dr.  West  as  the  facile  princeps 
of  British  obstetric  authors. — EUinb.  Med.  Journ. 


We  mustnnw conclude  this  hastily  written  sketch 
with  the  confident  assurance  to  our  readeis  that  the 
work  will  well  repay  perusal.  The  conscientious, 
painstaking, practical  physician  isapparent  on  every 
page. — A'.  Y.  Journal  of  Medicine,  March,  1858. 

We  know  of  no  treatise  of  the  kind  so  complete 
an'l  yet  so  compact. — Chicago  Med.  Journal,  Janu- 
ary, 185a. 

A  fairer,  more  honest,  more  earnest,  and  more  re- 
liable investigator  of  the  many  diseases  of  women 

BY  THE  SAME  AUTHOR.     {Nolo  Ready.) 

LECTURES   ON   THE   DISEASES    OF  INFaNCI  AND  CHILDHOOD. 

Third  American,  from  the  fourth  enlarged  and  improved  London  edition.     Iu  one  handsome 

octavo  volume,  extra  cloth,  of  about  six  hundred  and  fifty  pages.     $3  75. 

The  continued  favor  with  which  this  work  has  been  received  has  stimulated  the  author  to  ren- 
der it  in  every  respect  more  complete  and  more  worthy  the  confidence  of  the  prol'ession.  Con- 
taining nearly  two  hundred  pages  more  than  the  last  American  edition,  with  several  additional 
Lectures  and  a  careful  revision  and  enlargement  of  those  formerly  comprised  in  it,  it  can  hardly 
fail  to  maintain  its  reputation  as  a  cle»»r  and  judicious  text-book  for  the  student,  and  a  safe  and 
reliableguide  for  the  practitioner.  The  fact  staled  by  the  author  that  these  Lectures  '•  now  embody 
the  results  of  'JOO  observations  and  "288  post-mortem  examinations  made  among  nearly  oO,000 
children,  who,  during  the  past  twenty-years,  have  come  muier  my  care,"  is  suliicient  to  show  their 
high  practical  value  as  the  result  of  an  amount  of'  exjierience  which  few  physicians  enjcy. 

The  three  former  editions  of  the  work  now  before  i  diseases  it  omits  to  notice  altogether.  But  those 
us  have  placed  the  author  in  llie  foremost  rank  of  who  know  anything  of  the  present  condition  of 
lliosc  physicians  who  have  L'evotfd  special  attention  pajdiatrics  will  readily  admit  that  it  would  he  next 
to  the  iliseanes  of  early  life  We  aiteinpt  no  ana-  to  impossible  to  effect  more,  or  elfeot  it  belter,  than 
1}  lit  of  til  is  edit  ion,  l>ul  may  refer  the  reader  to  some  i  the  accoucheur  of  St.  Bartholomew's  has  done  m  a 
of  the  chapters  to  which  the  largest  additiiins  have  I  single  volume.     The  lecture  (XVl.)  up(ui  Disorcirs 


been  made — those  on  Uiplitheria,  Disonlcrs  of  the 
.Mind,  niid  lilincy,  for  instuiioe — as  a  prooi  that  the 
work  IB  really  u  new  edition;  not  a  mere  roprint. 
In  its  prcienl  shape  it  will  be  lound  of  the  greatest 
possible  service  in  the  cvery-day  prnetiee  of  nine- 
trnlliB  of  the  professKm. — Med.  times  and  Oazetle, 
L.'nd<.n,Dcc.  in,  l?ol>. 
All  tilings  considired,  this  book  of  Dr.  West  is 


of  ihe  Mind  in  children  is  an  admirable  specimen  of 
the  value  ol  the  later  inforinution  eonvejed  in  the 
Lectures  of  Dr.  Charles  W'esl. — London  Lancet, 
Oct.  2-2,  1S59. 

Since  the  appearance  of  the  first  edition,  about 
eleven  years  ago,  the  experience  of  the  author  has 
doubled  ;  so  that,  whereas  the  lectures  at  first  were 
founded  on  six  hundred  observations,  and  one  hun- 


hy  fur  the  best  treatise  in  our  language  upon  such  dred  and  eighty  dissections  made  among  nearly  four- 
niodihcations  of  morbid  action  and  diseise  as  are  teen  thousand  children,  they  now  embody  the  results 
witnessed  when  we  have  to  deal  with  infancy  and  I  of  nine  hundred  observations,  and  two  hundred  and 
childhood.  It  is  true  that  it  confines  itself  to  such  |  eighty-eight  post- mortem  examinations  made  among 
disorders  as  come  within  the  province  of  the  phy-  nearly  thirty  thousand  children,  who,  during  the 
iifian,  and  even  with  respect  tn  these  it  is  unequal  past  twenty  years,  have  been  under  his  care. — 
ns  regards  minuteness  of  consideration,  and  some  j  British  Med.  Journal,  Oct.  1,  1859. 

BY  THE  SAME  AUTHOR. 

AN  ENQUIRY  INTO  THE  PATHOLOGICAL  IMPORTANCE  OF  ULCER- 
ATION OF  THE  OS  UTERI.    In  one  neat  octavo  volume,  extra  cloth.    $1  00. 


GENERAL  LIBRARY 
UNIVERSITY  OF  CALIFORNIA— BERKELEY 

RETURN  TO  DESK  FROM  WHICH  BORROWED 

This  book  is  due  on  the  last  date  stamped  below,  or  on  the 
date  to  which  renewed. 

Renewed  books  are  subject  to  immediate  recall. 

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m...  rj 


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OCT  1  o  1954 

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